LCMS Convention Workbook St. Louis, Missouri — 2026, Page 198

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THEOLOGICAL DOCUMENTS­­—COMMISSION ON THEOLOGY AND CHURCH RELATIONS
T H E O L O G I C A L F O U N DAT I O N S

D. The Question of Euthanasia and What It Really Means

Lutheran catechesis reinforces the truth that the Fifth Commandment calls upon us to “fear and love God so that we do
not hurt or harm our neighbor in his body, but help and support him in every physical need.”70 The Ramsey Colloquium’s
directive “always to care, never to kill”71 echoes this tradition. “For Christians, each person’s life is a divine gift and trust,
taken up into God’s own eternal life in Jesus, to be guarded and respected in others and in oneself.”72
Physician-assisted suicide may escape the technical meaning of euthanasia since it “only” involves the physician in
prescribing the drugs that will end life when taken by the patient. Such specious logic cannot evade the fact that purposefully enabling an act is to participate in it. There is a difference, however, between enabling death and accepting its
inevitability. “Deeply embedded in our moral and medical traditions is the distinction between allowing to die, on the one
hand, and killing on the other.”73
Christian ethicists have made a strong case for the right to refuse or withhold medical treatments if they are either
“useless or excessively burdensome.”74 But, even here, to reject a treatment must never devolve into rejecting a life. It
engages others in a conspiracy to abandon, to kill another human being. Only flights of sophistry can disguise the fact that
despite all the language regarding choice and self-determination, euthanasia represents a license to kill.
The experience of the Netherlands may prove instructive. Euthanasia has been known to be regularly practiced in the
Netherlands since 1973, even prior to the current more permissive law.75 Indeed, one might argue that the 2001 law sought
to make legal what had been practiced behind closed doors in the previous decades.76 The official guidelines now require
that the patient’s decision is “voluntary, well considered and persistent, in the presence of unbearable pain without hope
of improvement.”77 They mandate the consultation with more than one doctor and concurrence between the physician
and the patient that euthanasia is the only reasonable option. Despite claims that the Dutch experience has been “virtually
abuse-free,” studies have consistently shown that cases of voluntary euthanasia have been underreported by less than half
of the actual cases for a variety of reasons (e.g., fear of being challenged for how strictly one followed the guidelines in the
law).78 Since 2002, euthanasia is regulated by the Termination of Life on Request and Assisted Suicide (Review Procedures)
Act. Rates for officially reported euthanasia have risen steadily in the Netherlands, from under 2% of all deaths in 2002
to more than 4% in 2019.79 But major skepticism exists as to how accurate the official numbers are, given the incentive to
avoid scrutiny, additional paperwork and the refusal by some physicians to report their euthanasia cases.
70

Luther’s Small Catechism with Explanation, 14.

71

The Ramsey Colloquium, “Always to Care, Never to Kill,” 45.

72

Meilaender, Bioethics: A Primer for Christians, 76–77.

73

The Ramsey Colloquium, “Always to Care, Never to Kill,” 45.

74

This distinction occurs repeatedly in the literature and is enshrined in Meilaender’s influential work.

T H E O L O G I C A L F O U N DAT I O N S

The experience of the Netherlands with its permission to euthanize provides us with a warning about the trajectory
of a society that surrenders the sanctity-of-life ethic and the protection of the weak and vulnerable. One suspects that in
a world of limited resources, the permission to die will soon morph into a duty to die. Heads of nursing homes, eldercare
attorneys and others in the senior living sector have reported dealing with greedy relatives trying to find a way to limit the
expense of care for a frail relative.80 Imagine if the person lived in a jurisdiction where the law permitted physician-assisted
suicide. Would terminally ill seniors be pressured to become “compassionate heroes” for their families to preserve more of
the inheritance? Common sense tells us that they would. The conjoining of legal permission with social acceptance would
result not in more freedom, but in less.81
Unfortunately, the logic of providing euthanasia leaves us with a major dilemma exposed by the Netherlands experience. Typically, euthanasia policies say that we should offer it as a right both because of our claims to self-determination
and in order to relieve suffering for the terminally ill. However, we have noted earlier (see “The Quest for Absolute
Autonomy”) that oftentimes these two criteria are separated in practice.
Meilaender has provided a strong defense of the rejection of euthanasia and affirmation of “double-effect” reasoning.82
With respect to euthanasia, he offers four simple observations. First, physicians are obliged to do what they can to relieve
the suffering of their patients. Here the “can” must be limited to “morally can.” A physician would be prohibited from doing
something that would relieve suffering but violate a moral code. Second, refusing to approve actions that are intended to
kill the patient does not imply that we must do everything possible to keep the person alive (e.g., it is sound medicine and
morally appropriate to refuse treatments that are useless or excessively burdensome). Third, the freedom to order one’s own
life is not absolute. We may not marry our sister, sell one of our kidneys to the highest bidder or take certain drugs. Fourth,
genuine compassion must respect the boundaries established by the Creator-creature divide. Hence, “we cannot give
ultimate authority over our life to another human being, nor are we authorized to exercise such authority over another.”83

Brian Pollard, “Current Euthanasia Law in the Netherlands,” Catholic Education Resource Center (2003), catholiceducation.org/en/controversy/euthanasia-and-assisted-suicide/current-euthanasia-law-in-the-netherlands.html. Gorsuch counts the much-celebrated 1984 assisted suicide that resulted in the Dutch Supreme Court siding with the physician on the grounds of “conflicting
duties.” Despite the nominally illegal nature of physician-assisted suicide in the Netherlands, the court found that the killing was justified by the doctor’s professional judgment about the quality
of his patient’s life. Neil M. Gorsuch, The Future of Assisted Suicide and Euthanasia (Princeton: Princeton University Press, 2006), 104–105. This legal protection expanded considerably in 1994
when “the Dutch Supreme Court held that, for a request for assisted suicide or euthanasia be justified on ‘necessity’ grounds, the patient’s suffering need not be physical, the patient need not
be terminally ill, and purely psychological suffering can qualify a patient for an act of euthanasia,” 105.
75

76

On this, see Ian Dowbiggin, A Merciful End: The Euthanasia Movement in Modern America (Oxford: Oxford University Press, 2003), 169.

77
Gorsuch summarizes the law as permitting assisted suicide and euthanasia when the physician: “1. holds the conviction that the request by the patient was voluntary and well-considered, 2.
holds the conviction that the patient’s suffering was lasting and unbearable, 3. has informed the patient about the situation he was in and about his prospects, 4. and the patient [held] the conviction that there was no other reasonable solution for the situation he was in, 5. has consulted at least one other, independent physician who has seen the patient and has given his written opinion
on the requirements of due care, referred to in parts 1–4, and, 6. has terminated a life or assisted in a suicide with due care,” The Future of Assisted Suicide and Euthanasia, 106.

Gorsuch devotes a major portion of Chapter 7 (103–116) to a thorough discussion of the Dutch experience with assisted suicide and euthanasia, including a critical review of major studies.
He observes that “the Surveys have consistently found that a significant proportion of assisted suicides and acts of euthanasia go unreported, even though Dutch professional and legal guidelines
allow the practices and expressly require them to be reported to public authorities,” The Future of Assisted Suicide and Euthanasia, 113.
78

79
See “A Critical Look at the Rising Euthanasia Rates in the Netherlands,” as reported by healthcare-in-europe.com (Jan. 15, 2021), https://healthcare-in-europe.com/en/news/a-critical-look-at-therising-euthanasia-rates-in-the-netherlands.html.

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Medicare in the United States, for instance, does not provide for “custodial care” in nursing homes and senior living communities. Some family members have objected to depleting their loved
one’s financial resources on “useless” care. In order to qualify for the government aid that may be available, some families enter into convoluted legal mechanisms for shielding assets. An entire
specialty of law focuses on means to transfer assets into legal instruments that make a frail senior appear to be penniless and in need of government-provided nursing home care.
81

Consider the arguments Meilaender makes regarding this in Bioethics: A Primer for Christians, 75–80.

82

Gilbert Meilaender, Bioethics and the Character of Human Life: Essays and Reflections (Eugene, Ore.: Cascade Books, 2020), 121–132.

83

Meilaender, Bioethics and the Character of Human Life, 123. It is important to note that Meilaender refers to “ultimate authority” and is not speaking against something such as a health POA.

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ings and of conversations that take place. “Patients are not blind. They see the offering or non-offering of appropriate food
and fluids as an expression of love and concern or lack of love and concern.”87 Tube feeding should never be deemed useless
or futile if it sustains life and prevents death by starvation or dehydration.88 Since a patient’s life is God-given, we will not
deem a treatment futile that sustains the life, “even though we might all agree this is not the life anyone would choose
for himself.”89

III. Medical-Ethical Considerations
The Commission recognizes that a host of medical and ethical matters come to bear as we face the end of earthly life for
ourselves or our loved ones. Many of the issues have to do with making decisions about treatment — what sort, how long,
how do we decide and so forth. The following are some of the matters that must often be considered. What about matters
such as the use of devices to help with breathing or procedures that provide hydration and nutrition? Is there sometimes an
appropriate time to stop the use of such artificial means for prolonging a physical life? And who should make such decisions — patients, their family, doctors? Are advance directives advisable? Are they absolute?
There are many such questions. The items below seek to address some of them, in no particular order of priority or
logical progression.

A. Ventilators and Medical Prolongation of Life and Dying

Elizabeth R. Skoglund observes, “If a respirator or ventilator can be a bridge back to life, then we have the obligation to try
it. If, on the other hand, the respirator is used when death is inevitable, simply to slow the dying process, then it is wrongfully keeping us from being released to be with God.”84
Do Not Resuscitate (DNR) orders often involve the issue of ventilators. A DNR designation refers to a medical order
making clear an individual’s request that no measures be taken to resuscitate him if his heart or breathing stops. The order
is made while the individual is mentally capable and conscious, or by his health care proxy if he is not. DNR covers a wide
range of specific instructions to health care providers. Some patients may choose to have “full code” with intubation and
to be placed on a ventilator (short or long term). Another patient may decide not to be on a ventilator with a “DNR Select”
code status, where the heart would be shocked if it stops but intubation/ventilation is not performed. Some in this category
choose to permit use of a BIPAP (similar to a CPAP for sleep apnea) to assist with breathing. A third option involves a
patient that chooses to have a status of Do Not Resuscitate (DNR). Various treatments (e.g., antibiotics, tube feeding) and
other care preferences can be specified on some DNR forms in some jurisdictions to guide health team members.
As for medically assisted nutrition and hydration, Luther’s words are on point when he reminds us in the Small
Catechism that “we should fear and love God so that we do not hurt or harm our neighbor in his body, but help and
support him in every physical need.”85 He expands on this in the Large Catechism by explaining “this commandment is
violated not only when we do evil, but also when we have the opportunity to do good to our neighbors and to prevent,
protect, and save them from suffering bodily harm or injury but fail to do so. … If you see anyone who is suffering from
hunger and do not feed her, you have let her starve.”86 Even in a state of coma, patients are often aware of their surround84

Bartlett and Rehder, “Ventilators, Feeding Tubes, and Other End-of-Life Questions,” 2.

85

Luther’s Small Catechism with Explanation, 14.

Kirsi I. Stjerna, “The Large Catechism of Dr. Martin Luther,” in Word and Faith, ed. Hans J. Hillerbrand, Kirsi I. Stjerna and Timothy J. Wengert, vol. 2, The Annotated Luther (Minneapolis:
Fortress Press, 2015), 329.
86

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The concern that oral tube feeding runs the risk of infection or that it may even lead to incidental aspiration that may
result in pneumonia hardly stands up to scrutiny. If one method of delivering nutrition and hydration proves problematic,
there are other means to do it. The so-called “G-tube,” for instance, provides a long-term alternative to the short-term nasogastric delivery of nutrition and hydration following a minor surgical procedure. Placement of a G-tube can be performed
in three ways: surgically through making small incisions guided by a laparoscope, surgically by means of an open incision
to the abdomen, or endoscopically employing a scope into the stomach to create the stoma from the inside.
One might reasonably ask if ever removing artificial nutrition and hydration represents a permissible act. Here the
question revolves around whether one is “allowing a person to die” or is intending to cause death. This paper affirms the
principle that withholding or withdrawing treatments may be done when it becomes useless or excessively burdensome.
In many end-of-life situations, the continued administration of hydration and nutrition may create rather than ameliorate
problems.90 For instance, if the kidneys no longer process fluids for elimination, adding fluids artificially may result in
painful edema (swelling). Yet, we are reminded that the burdensomeness is that of the treatment, not of life itself. We are
called to care for other persons and do all that we can reasonably do to assist in sustaining their lives. Certainly, fulfilling
the commandment not to kill, but to “fear and love God so that we do not hurt or harm our neighbor in his body, but help
and support him in every physical need” ordinarily includes supplying food and water.91
Another question involves comatose patients. Are we morally obligated to sustain their lives by means of artificial
nutrition and hydration when the very fact of being in a persistent vegetative state makes any return to normal life highly
unlikely? But, even here, the annals of medical science are replete with examples of remarkable, even miraculous, recoveries from an unconscious or persistent vegetative state. For instance, Munira Abdulla (born 1959), an Emirati woman,
lapsed into a coma following a car accident and regained consciousness after 27 years.92 While for a conscious patient, the
use of tube feeding may prove terrifying and lead to a state of extreme agitation, an unconscious person would (obviously)
not experience treatment as excessively burdensome. This illustrates the distinction between a treatment imposing an excessive burden and family members wishing to be relieved of the burden of sustaining a person’s life. Meilaender correctly
notes that such care cannot be described as “useless, since it preserves the life of the embodied human being (who is not a
dying patient).”93 To withdraw or withhold nutrition and hydration from a person means certain death. Regardless of our
professed motives, we would be aiming at the death of the person. For this reason, sensitive ethicists such as Meilaender
conclude: “For the permanently unconscious person, feeding is neither useless nor excessively burdensome. It is ordinary
87

Bartlett and Rehder, “Ventilators, Feeding Tubes, and Other End-of-Life Questions,” 3.

88

Bartlett and Rehder, “Ventilators, Feeding Tubes, and Other End-of-Life Questions,” 3.

89

Richard Eyer, Holy People, Holy Lives (St. Louis: Concordia Publishing House, 2014), Kindle Edition, locations 1202–1203.

For a thorough discussion of the morality of withholding food and water, cf. Joanne Lynn and James F. Childress, “Must Patients Always Be Given Food and Water?” in By No Extraordinary
Means, ed. Joanne Lynn (Bloomington: Indiana University Press, 1986), 47–60. “The question is whether the obligation to act in the patient’s best interests was discharged by withholding or
withdrawing particular medical treatments. All we have claimed is that nutrition and hydration by medical means need not always be provided,” 59. In the same book, Daniel Callahan frets that
mounting social and economic pressures will precipitate “prematurely terminating nutrition” rather than providing it for too long after it becomes burdensome. Callahan, “Public Policy and the
Cessation of Nutrition,” 65. Childress follows Callahan’s chapter and cautions against self-deception. He argues that we should make these decisions with clear-eyed awareness, accepting moral
responsibility for the lines we draw and limits we set. Childress, “What is Morally Justifiable to Discontinue Medical Nutrition and Hydration?” 67–83.
90

91

See CTCR, Christian Care at Life’s End, for further discussion of these kinds of difficult and challenging decisions.

92

“UAE Woman Munira Abdulla Wakes Up After 27 Years in a Coma,” BBC News Service, April 23, 2019, bbc.com/news/world-middle-east-48020481.

93

Gilbert Meilaender, “On Removing Food and Water: Against the Stream,” The Hastings Center Report 14, no. 6 (December 1984), 13.

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