LCMS Convention Workbook St. Louis, Missouri — 2026, Page 200

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THEOLOGICAL DOCUMENTS­­—COMMISSION ON THEOLOGY AND CHURCH RELATIONS
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we noted earlier.112 For these reasons, we suggest that living wills do not represent the best means for loved ones to exercise
their God-given responsibilities to provide compassionate care for their loved ones. “In the end, no legal instrument can
substitute for wise and loving choices, made on the spot, when the precise treatment dilemma is clear and care decisions
are needed.”113
Rather than endorsing living wills, many sensitive ethicists, both Christian and non-Christian, have instead defended
the use of proxy directives such as a durable power of attorney (POA) for health care. A POA for health care avoids the
impossible task of guessing what a legally incompetent person might want given the particular clinical circumstances near
the end of life. Instead, it rightfully burdens those who loved her with asking a far more relevant question: “What is best for
her now?”114
Some might argue that durable POA documents share with living wills a desire to reach into a future beyond the
scope of time when we are fully competent to direct our own care. But unlike the living will, which extends its reach by
means of legal specifications to guarantee the patient’s own wishes and autonomy, the proxy affirms the individual’s creaturely dependence and his need to rely upon others.
A health care POA designates that an individual, as the principal, appoints another person to be his agent to make
health care decisions if he is unable or unwilling to make them.115 A POA for health care should not be confused with a
POA for property or business transactions, which appoints a person to make business- or property-related decisions. Even
though the health care POA may not necessarily be making decisions, the agent most often has access to applicable medical
records. Many jurisdictions provide for the health care POA to be durable, which means the agency designation remains in
place even though the principal no longer retains ability to make decisions for himself or herself.
The selection of a health care agent is a critical decision as the agent will have ultimate authority for decision-making
even after the individual is no longer able to express their own wishes. The individual chosen to be the health care agent
should be someone with the capability to make decisions even if other family members are not in agreement.
It is normally prudent to choose a single health care agent. Commonly, one or two successors can be named in a
health care POA, but only in an order of priority. Naming two individuals as health care co-agents only provides an opportunity for conflicts and stalemates and, therefore, the possibility that no decision is made.

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for love and care in the past. Now, when I can no longer participate in decisions about my medical care, I am content to
continue to be dependent upon his love and care. Talk with him about what is best for me.”116

D. The Question of When Enough Is “Enough”

When is a treatment useless? When is a treatment excessively burdensome? A commitment to the sanctity of life and a
refusal to accept physician-assisted suicide does not involve an idealistic effort to sustain biological life at all costs. When
all indications point to God calling the soul from the body, “there is no point in merely blowing wind through the empty
tent with ventilators and machines.”117 When death appears imminent, the decision to withhold or withdraw food and
hydration is not deciding to kill. Rather, it represents an important aspect of caring for the dying person. We do not wish to
add burdens to the patient at such a time, but to relieve him of additional burdens.
While it may be appropriate to withdraw or withhold nutrition and hydration for someone who is imminently dying,
that does not mean that we may act in this way because a patient is not dying fast enough. As fallible men and women
with deceitful hearts (JER. 17:9), it is easy to deceive ourselves with faulty reasons for why we should hasten death. Hospital
and skilled nursing facility nurses have all heard families use a patient’s poor “quality of life” as a reason to suspend treatments. Others speak of the psychological toll that a prolonged dying process may have on a physically frail or emotionally
unstable spouse or other family members to rationalize a speedier death. An adult child may protest that this “useless care”
is sapping the limited savings that the surviving parent will need to “get by.” No doubt selfishness motivates some heirs who
would rather a patient die quickly so their inheritance will not be used for patient care.
Despite such specious reasoning, we acknowledge that there are times when it is inappropriate to provide nutrition
and hydration artificially. Depending on the specific condition, when major organs begin to fail, nutrition and hydration
may actually increase the discomfort the body experiences after it no longer accepts or processes such sustenance effectively. In the active stages of dying, deterioration of the digestive tract can lead to discomfort and bloating. Similarly, as the
heart becomes weaker and less efficient in pumping blood, fluid overload creates several negative conditions including fluid
backup in the lungs, respiratory distress and excessive swelling of the tissues.
The Christian Medical and Dental Associations promotes a four-option approach to dealing with the ethical issues
presented by artificial nutrition and hydration (ANH):

Many times in a health care POA, an individual expresses certain wishes for how they want end-of-life decisions to be
made. It is important the health care agent chosen be an individual well-grounded in the principal’s spiritual foundation as
well as their personal wishes. This helps to ensure that the health care agent is well equipped to assimilate the medical and
health care facts that are unfolding and make appropriate, timely decisions.

•

Strong indications for use of ANH include patients with an inability to take oral fluids and nutrition with a high
probability of reversing it; a patient in a stable condition but who is unable to swallow; a patient with a newly
diagnosed but not imminently fatal severe brain impairment; gastrointestinal tract failure or need for bowel rest;
or a fully informed patient wishing to survive until an important life event.

Rather than a living will, the health care POA offers a better option for directing end-of-life care. As Meilaender
concludes, it makes a simple statement to health care providers: “Here is a person upon whom I have often been dependent

•

Allowable indications for use of ANH speak to a morally neutral situation where a patient or surrogate should
make the best decision after consulting with appropriate medical personnel. Examples would include a patient
wishing to prolong life despite a severe and progressive neurologic impairment (e.g., end-stage amyotrophic
lateral sclerosis, also called Lou Gehrig’s disease or ALS) and situations in which there is uncertainty whether the
anticipated benefits versus burdens justify the intervention.

•

Not recommended but allowable indications for ANH include when a patient or surrogate asks to overrule the
patient’s advance directive due to a specific or changing clinical context.

See pages 41–42. The 2005 report Taking Care devotes an entire chapter, pages 55–93, to “The Limited Wisdom of Advance Directives.” This report of the President’s Commission on Bioethics
articulates multiple reasons for rejecting the living will in favor of power of attorney proxies and legal surrogate instruments.

112

113

Taking Care, 56.

114
Cf. Taking Care, 55–93, where the legal rulings in landmark 20th-century cases are discussed in terms of various permutations of subjective and objective standards, including “substituted
judgment” and “best interest” standards.
115
Power of Attorney documents vary widely, yet many jurisdictions have their statutory Health Care POA formats available online through their health departments or they may be accessed
through a party’s legal counsel or health care provider. It is important to nsure that current documents reflecting a person’s end-of-life wishes are readily available and locatable when they may
be needed.

•

Meilaender, Bioethics: A Primer for Christians, 104.

117

Bartlett and Rehder, “Ventilators, Feeding Tubes, and Other End-of-Life Questions,” 8.

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Unallowable indications where it is unethical to employ ANH include administering it against the patient’s or
surrogate’s express wishes, compelling medical professionals to participate in ANH insertion in violation of their
conscience, or utilizing ANH when the patient is declared brain dead. 118

E. Refusing or Withdrawing Treatment

In discussing the ethics of refusing treatment, several authors cite a helpful metaphor, known as “the good host,” first proffered by the Anglican David H. Smith.
A couple invite friends to dinner. Food and drink are pleasant; the conversation bubbles. The good host is hospitable and courteous to his guest, no matter what his shifts in mood. But there comes a time when the party
“winds down” — a time to acknowledge that the evening is over. At that point, not easily determined by clock,
conversation or basal metabolism, the good host does not press his guest to stay but lets him go. Indeed he may
have to signal that it is acceptable to leave. A good host will never be sure of his timing and will never kick out
his guest. His jurisdiction over the guest is limited to taking care and permitting departure.119
The illustration compares end-of-life decisions to the hospitality offered by a good host. The good host neither pushes
his guests out the door too early nor does he inveigh upon them to remain after the end of the party.120 While a growing
number of jurisdictions may permit physician assistance in facilitating the deaths of their patients (e.g., by prescribing
the lethal medication for the terminal patient to take), Christian ethics does not choose death or aim at it. Here it must be
stated that neither do we make a false idol out of biological life as if it were the only or highest good.121
Unlike those availing themselves of the permission in those states with physician assistance in suicide laws, we are not
called to choose death or aim at it. However, refusing treatments, even life-saving ones, may be a correct Christian choice.
At 86 years of age, Polycarp, the Bishop of Smyrna, was taken to the arena. The proconsul attempted to persuade him to
curse Christ and he would be free to go. But Polycarp refused, saying: “For eighty-six years I have served him, and he has
done me no evil. How can I curse my king, who saved me?”122 While Polycarp freely answered the proconsul’s questions,
expecting that it would result in his death, he did not do so intending or aiming at death.123 The same moral reasoning
applies to the soldier who sacrifices his life willingly for the well-being of others. While one might reasonably know or
suspect that making a charge against overwhelming odds will result in one’s death, this is not an act of suicide. Dying may
be the most likely outcome, but it is not part of the soldier’s plan of action.
Many end-of-life treatments to reduce pain will carry negative, even possibly lethal, side effects. The narcotic
morphine, for example, has become a commonly prescribed end-of-life medication to relieve severe pain that does
not respond to other analgesics. As the patient’s pain increases, caregivers typically administer larger doses of the
118

“Position Statements,” Christian Medical & Dental Associations® (CMDA), March 23, 2022, https://cmda.org/policy-issues-home/position-statements/.

119

David H. Smith, Health and Medicine in the Anglican Tradition (New York: Crossroad, 1986), 52.

120
Hauerwas cites Daniel Callahan’s recapturing of the meaning of “natural death” with some qualified approval since the phrase itself may be too misleading to be of much help. Hauerwas
instead opts for the description of a “good death.” Hauerwas, Suffering Presence, 98. Callahan defines “natural death” as one when (1) one’s life work has been accomplished; (2) one’s moral
obligations have been discharged; (3) one’s death will not seem an offense to sense or sensibility; and (4) one’s process of dying does not involve “unbearable and degrading pain,” 97. Hauerwas
quotes Eberhard Jungel as teaching that the Christian proclamation of Jesus Christ freeing us from the curse of death implies that “human life has a natural end which comes when the time
allotted to life has expired. Man has a right to die this death and no other.” Hauerwas, Suffering Presence, 97. Hauerwas concludes that we ought not allow the “symbol of brain death to tyrannize
us by requiring that we delay death so long that we can no longer die a good death … it should not be used as a substitute for the responsibility each of us has to die our own death.” Hauerwas,
Suffering Presence, 98.
121
Hauerwas asserts that “we should die in such a manner that others see that they are sustaining us and that correlatively due credit is given to God as the ultimate giver of life.” Hauerwas,
Suffering Presence, 96.
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116

Justo L. Gonzalez, The Story of Christianity, Vol. 1. (Peabody, Mass.: Prince Press, 1984), 43–45.

This differentiation between intention and result plays a large role in Roman Catholic moral philosophy and has been credited to Thomas Aquinas. The so-called doctrine of “double effect”
also comes into discussions of sedation, which may ease pain and may also hasten death. Note that while this notion becomes quite important in Roman Catholic medical ethics, there are some
who dispute the appropriateness of it. David VanDrunen, for instance, refuses to employ the category as such because he deems the criteria not “always helpful” and argues that the use of it
proves unhelpful as a rule to “determine the application of the principle on every occasion.” Cf. VanDrunen, Bioethics and the Christian Life, 213–238.
123

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drug.124 Morphine not only deadens pain; it also suppresses respiration. The aim of the treatment, however, intends to
mitigate pain and not to cause the death of the patient. If a caregiver deliberately overdoses the patient in order to euthanize him, we would say that he killed him since death was the physician’s aim. If, however, a carefully adjusted dose
of morphine to relieve pain suppressed respiration and the patient died, we would not reach the same determination
since death was not the intent. This has led to the following guidelines for the moral answer to questions of refusing or
withdrawing treatment.125
First, a treatment may be refused if it is useless for the person relative to his condition. Since there is no moral obligation to undergo treatments that hold little prospect of curing or even ameliorating the symptoms of a disease, refusing to
accept a particular treatment does not equal the rejection of the gift of life.
In some cases, the refusal of treatment is more than “allowing to die,” it is done in order that the individual will die. A
parent who will not allow a baby with Down syndrome to receive a necessary surgery might be said to refuse the surgery
so that the child will die. This kind of verbal trickery has become more popular in our era when we tend to think of personhood in terms of skill sets and cognitive abilities. For example, the evangelist and motivational speaker Nick Vujicic was
born with tetra-amelia syndrome, leaving him without arms or legs. Had he also suffered from a blockage in his digestive
system requiring surgery, one might easily have imagined his parents asking if he might be a candidate for euthanasia in a
nation such as the Netherlands.
Second, treatments that are useful and perhaps even lifesaving may sometimes be excessively burdensome. In such
cases, because life is not our god, we are not called upon to bear all burdens in order to stay alive. A variety of medical
procedures, treatments and even medications may prolong life, but at an unwarranted burden. The patient chooses life, not
death, simply not the life promised by the particular medical treatment. Elderly cancer patients, for instance, may choose
not to accept the recommended chemotherapy because of the burden of the side effects.
As in the first guideline, this one may be abused quite readily. If we confuse the burdens of treatment with the burden
of life, we move into an ethical danger zone. During the last several decades, for instance, the news has brought stories of
Karen Quinlan and Terri Schiavo to our attention. None of us would wish for an unconscious existence in a persistent vegetative state, sustained by artificial nutrition and hydration. But, as Meilaender has wisely said, “if we act on such a thought
and withdraw the feeding tube, the burden at which we are taking aim is not treatment but life itself.”126 Christian wisdom
says that if the treatment will benefit the life the patient has (whether we would choose such a life for ourselves or not), we
are called to choose life.

F. Financial Matters

Since insurance policies, government provisions for coverage and state-specific legislation vary greatly and change rapidly,
it would not be possible to address all of the practical matters related to how finances intersect with the convictions of a
faithful Christian end-of-life ethic. Nevertheless, a few observations must be made.
Given the growing acceptance of assisted suicide, it is almost certain that withholding medical care for the terminally
ill and for those with cognitive and other functional deficits will increase, and that some of that increase will be for financial reasons. Rising medical costs for lifesaving or life-prolonging treatments come into sharp conflict with the strictures of
124
Not only medical caregivers, but also family members may sometimes be authorized to administer morphine. It would be vital in such cases that there be instruction in the proper way to do
so, as well as counsel concerning the distinction between caring and killing.
125
The following points are so common to end-of-life books and articles that they hardly require detailed documentation, and are commonly identified by Roman Catholic, Reformed (e.g., VanDrunen) and Lutheran ethicists. Lutheran ethicist Meilaender, for instance, often lists these as helpful principles. The reader may be directed to Meilaender’s Bioethics: A Primer for Christians,
84–87, for a summary in his section “Guidelines.”
126

Meilaender, Bioethics: A Primer for Christians, 87–88.

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