18 July 2008

The Pastor vs. The Clinical Ethicist

So one of the faithful is near death.

He has had complications following treatment for cancer and has been on a ventilator for 7 months or so. He was in rehab and was finally being weaned off the vent, but on Monday he developed an infection and went into kidney failure; along with very low blood pressure. He is now in the ICU on the vent, dialysis, medication to keep his blood pressure up and continued antibiotics to fight the infection.

Today the physicians told the family that there was nothing more that could be done....and that it would probably be a good thing to make him more "comfortable". They were told that an increased dosage of the morphine he was already on for pain would most likely counteract the blood pressure medication and as a result he could die comfortably within 1-2 hours. None of the other treatments would be removed mind you, but comfort would be given. So the pastor was called...please come as soon as you can.

This faithful man was the chairman of our parish's Lutherans for Life group. He is a man of life and having spoken about such things with him, I knew that this was no road that he would want his family to go down, but rather he would continue to live as he had for all these months, in real suffering, but also in real hope. His wife and children are faithful Christians, members of our parish together. His dear wife particularly was troubled by all of this talk from the drs., and wanted to hear from the pastor, but most importantly from the Word what should be done. There was a crisis of faith. So I stated that by no means would we do anything to hasten his death, rather we would put the comforting words of Christ into his ears. We discussed the suffering of our Lord, and the sanctified suffering of those who bear the cross as Christians. Also that the 5th commandment holds. They heard the Word of God and were happy to be freed from the foothold of Satan who would plague them with guilt over wanting it "all to be over with and his suffering to end." And as his wife even said, "I am tempted to want them to do this, so I won't have to keep on coming to these places and see this all." She knew the temptation and fought it; the temptation to live for herself, instead of living in faithfulness to her Lord and her husband. So at the end of a long conversation there was really no decision to be made, he would live with what they were giving him until the Lord would have His way.

So one of the nurses was in the room listening to much of this, and the man's wife told her that they were to continue all the current treatments but were not to increase the morphine because as she said, "We don't believe in euthanasia." The nurse's reply was, "Our clinical ethicist is on the floor and I know that he would be willing to speak with you." Now mind you I dress the part of the preacher, but what the preacher had told the family and what the family had seen as the way obviously did not resinate with this nurse. So she went to get him. And we braced ourselves for what he would say, more out of curiosity more than anything else I think. With one of the children saying something like, this should be interesting.

So in walks the guy, sits down, gives his first name only (what exactly his credentials are to be a clinical ethicist no one knows) and basically attempts to convince the family, in my presence mind you, of the need to "figure out what the goal here is. Is it to simply keep him alive as long as we can, or is it to make him comfortable?" I was waiting for some ethics to start coming out of his mouth but got no such thing. Again the dear wife, "We do not believe in euthanasia." Defensiveness from the clinical ethicist, "no, no that is not what I'm saying. We wouldn't remove any other of the medications or devices, but make him comfortable, that comfort might result in his death, yes if the blood pressure goes down." Again, this comfortable business. I was waiting for him to bring something up about letting him go to a better place or some such thing, but he basically gave the apologia for comfort over suffering, stating that the death might be painful and difficult without the increased medication. Really, death is difficult and painful, who knew? So the wife excused him, we made up our minds thank you.

So he left, having brought no real ethics to bear, because he came empty handed with no word of Christ, no guidance from the scriptures. No words like

"For as many as are led by the Spirit of God, these are sons of God. For you did not receive the spirit of bondage again to fear, but you received the Spirit of adoption by whom we cry out, “Abba, Father.” The Spirit Himself bears witness with our spirit that we are children of God, and if children, then heirs—heirs of God and joint heirs with Christ, if indeed we suffer with Him, that we may also be glorified together. For I consider that the sufferings of this present time are not worthy to be compared with the glory which shall be revealed in us. For the earnest expectation of the creation eagerly waits for the revealing of the sons of God." Romans 8:14-19

"Therefore humble yourselves under the mighty hand of God, that He may exalt you in due time, casting all your care upon Him, for He cares for you. Be sober, be vigilant; because your adversary the devil walks about like a roaring lion, seeking whom he may devour. Resist him, steadfast in the faith, knowing that the same sufferings are experienced by your brotherhood in the world. But may the God of all grace, who called us to His eternal glory by Christ Jesus, after you have suffered a while, perfect, establish, strengthen, and settle you. To Him be the glory and the dominion forever and ever. Amen." 1 Peter 5:6-10

Then He said to them all, “If anyone desires to come after Me, let him deny himself, and take up his cross daily, and follow Me. For whoever desires to save his life will lose it, but whoever loses his life for My sake will save it. For what profit is it to a man if he gains the whole world, and is himself destroyed or lost? For whoever is ashamed of Me and My words, of him the Son of Man will be ashamed when He comes in His own glory, and in His Father’s, and of the holy angels. St. Luke 9:23-26

Jesus really means this business of bearing the cross, of denying the self of following him in suffering with the promises of resurrection and glory to come. We want to avoid this reality, and in doing so we are very tempted to avoid the glory of the cross itself, that God has done His greatest work in the suffering of His Son. The cross, it is His glory, it is our life. The promises that He gives through the Apostles are real too, of eternal glory of suffering a little while and receiving His gifts, real.

That it why it was with such joy that we prayed the Commendation of the Dying. Reading St. Matthew's Passion to a dying man, and to his family and telling him that because of Christ's suffering, of the fact that the Father forsook His Son, he was not forsaken in that room, nor would he ever be. That he was baptized into that one death, that his sins were truly atoned for and forgiven; that he was free from them and from death itself. And then to read St. John's account of the resurrection, "go to My brethren and say to them, ‘I am ascending to My Father and your Father, and to My God and your God.’” Telling him that Christ has been raised that He is now at the Father's right hand, the one mediator who has destroyed death, who has prepared a place for him and will take him to his side with all the saints. And then the fulness of his baptism into Christ's death and resurrection to come, his own resurrection on the last day. That he has a true Father in heaven, because he has all that the Son is and has through Holy Baptism. All of this is the real comfort, not some drug, these Words. And I got to rejoice in the faithfulness of these people, commending their husband and father completely to the Lord knowing what he would face, but that he would face it with clarity of mind and they with clarity of conscience.

Talking to a brother pastor this evening, he said it was his experience all to often that the decision for "comfort" has won out, and that usually the decision is made well before he arrives at the hospital by relatives that are not among the faithful. I am wondering what you brethren think about all of this. Of course this isn't the first time I have had to deal with such things, it is the first time the clinical ethicist has shown up. Clinical ethicists called in when the family's pastor is present? Bizarre. But I am guessing that the clinical ethicist and the nurse and whoever else thought that the family and the pastor were really the bizarre ones.

It is one of those where the funeral sermon is going to write itself.

Pr. BT Ball+


Pr. H. R. said...

I use the Papists' Ethical and Religious Directives for their hospitals and selected parts of the CTCR document on End of Life decisions for when families have one of these coming. They are very helpful.

Once again we find ourselves ashamed that the Papists have thought these things through and provide their institutions with very clear guidance, and we have. . . a short paper from the CTCR.


The Rev. BT Ball said...

directive 61, very helpful. "Patients should be kept as free of pain as possible so that they may die comfortably and with dignity, and in the place where they wish to die. Since a person has the right to prepare for his or her death while fully conscious, he or she should not be deprived of consciousness without a compelling reason. Medicines capable of alleviating or suppressing pain may be given to a dying person, even if this therapy may indirectly shorten the person's life so long as the intent is not to hasten death. Patients experiencing suffering that cannot be alleviated should be helped to appreciate the Christian understanding of redemptive suffering."

It certainly seemed in this particular situation that there was no stated intent to hasten death, but it was certainly clear that the increased dosage of pain medication would do just that. But the matter of intent is what was getting at the family and as I said was allowing great temptation to enter in.

Also, he was able to respond to communication, the increased dosage would have ended that.

And an update, in the middle of the night he rallied, so that his blood pressure has improved and those medications have been decreased.

Anyway the link for the papist document Heath mentioned-


Rev. Rick Stuckwisch said...

Brother Ball, this is not only a beautiful post, but extraordinarily helpful. In confessing the Word of God and the genuine comfort of the Cross -- to this Christian gentleman and his family, and now also to us here -- you also serve to catechize us and others in genuine pastoral care.

I have never encountered a situation quite like the one that you have described. I'm not sure that I would have had the same presence of mind as you displayed, but here I have been well-served to learn from your example. For that I am most grateful.

Frankly, all of the things that I am able to do well as a pastor, are things that I learned from the example of my own pastors, from my fathers and brothers in the Office. It is a tangible example and continuation of the Apostolic tradition: received and handed over from the fathers to the sons, and so also from brother to brother.