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LCMS Convention Workbook St. Louis, Missouri — 2026, Page 201

Scan: The Lutheran Church—Missouri Synod

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THEOLOGICAL DOCUMENTS—COMMISSION ON THEOLOGY AND CHURCH RELATIONS

201

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budgets and bottom-line considerations by insurance companies. This becomes particularly true in an era when a Christian
value on life seems less “cost effective” to those who think only of human life in pragmatic and non-theistic terms. As
long ago as 1984, Colorado Governor Richard D. Lamm argued that there simply would not be enough money to fund
all of the possible technological interventions that medical science presents. Lamm, a former certified public accountant,
earned the moniker “Governor Gloom” for suggesting that the elderly have “a duty to die and get out of the way with all
of our machines and artificial hearts and everything else like that and let the other society, our kids, build a reasonable
life.”127 John Kilner makes several solid criticisms of age-based rationing of life-sustaining medical care. After considering a
variety of utilitarian considerations, he concludes, “Our elderly and aged deserve our respect and our protection. Rationing
their health care because of their age is to treat them with disdain rather than with dignity.”128 As a variety of ethicists have
observed, the unintended consequences of loosening the restrictions on physician-assisted dying and euthanasia may result
in a rapid closing of the distance between personal preference and the morally obligatory. What may begin as a possible
course of action based on the wishes of the terminally ill person may soon become a “duty to die and get out of the way.”
Such opinions seem even more persuasive when medical resources are scarce, and beds, medications, oxygen and other
means of care are rationed and perhaps unavailable to those with a better chance of survival.

As in most areas of life, advance planning can be extremely helpful. It is generally advisable for those who qualify
and can afford it to carry long-term care insurance. However, with annual costs that can be significant, that option will not
be practical for persons of lower income and/or savings. Additionally, many applicants for long-term care insurance will
be rejected due to pre-existing conditions (including, among others, inability to pass a cognitive test, obesity and certain
chronic conditions).

The selection of physician, hospital and hospice program directly impacts the approach to end-of-life treatments.
Patients and their health care surrogates need to ask whatever questions are required in order to discover the approach
their health care provider will take when faced with terminal conditions, incapacity and possibly prolonged custodial care.
It would be better to change physicians than to have one who was reluctant to cooperate with the wishes of the patient
or POA when determining next steps for the hospital or hospice. Remember also that hospice aims to support the family
in offering palliative medication and emotional support, not provide restorative therapies. Doing one’s due diligence in
researching and contracting with the hospice organization that will fit your needs is paramount. Similarly, while dedicated
hospice in-patient facilities offer much greater care, they also have their own policies and procedures that may not align
with the convictions and concerns of the family for caring for their loved one. Inquiries with hospice programs and in-patient programs can determine what one may expect prior to signing up with the hospice.
The choice of the agent granted durable power of attorney for health care should similarly be considered seriously.
Family dynamics may present the POA with decision-making in an unenviable environment. One child may feel guilty
about how she treated mom and wants to do everything medically possible to prolong life, while another one may be struggling with financial reverses and secretly hopes that enough money will be available in the estate to rescue him from fiscal
ruin. Those chosen to carry the responsibility of POA should be able to resist the temptations of competing voices and to
decide based on what is best for the loved one.
One potential cause of conflict over patient care can occur when different individuals are given responsibility for the
medical POA and the financial POA. For example, a parent may designate one child to handle the POA for finance and
another to assume the POA for health care. This may seem advisable if one child has a health care background and another
has a demonstrated skill in handling money. But the arrangement can also lead to unhappy consequences. The person responsible for managing the financial affairs could conceivably refuse to allow payment for a high “out of pocket” course of
treatment endorsed by the child with the medical POA.

G. Necessary Distinctions and Helpful Terminology
1. Burdens of Treatment vs. Burdens of Life
Earlier we introduced the matter of medically useless or excessively burdensome treatments. Along with most Christian
ethicists, we affirm that no one should be subjected to a treatment that would be useless. But beyond this, no one need
agree to every treatment proposed by physicians, regardless of how lifesaving it may be, if the treatment is excessively burdensome. Many cancer chemotherapy regimens, for instance, may produce extremely difficult side effects, particularly for a
very aged individual. Some patients may elect to spend time with family or friends rather than accepting a grueling course
of chemotherapy with little possibility of extending life.
Refusing a particular course of medical treatment because it proves too burdensome on the patient is radically different from considering the very life of the dying person to be a burden. A person may suffer from the burden of frailty due to
age, accident or chronic illness. In some cases, such conditions may cause us to pray for God’s deliverance from them. They
are nonetheless common to our human condition and not a ground for suicide or euthanasia. “We may reject a treatment;
we must never reject a life.”129
2. Caring, But Only Caring
The Ramsey Colloquium’s declaration “always to care, never to kill” summarizes the Judeo-Christian tradition with respect
to our obligations to our fellow creatures.130 It also echoes the moral consensus of the Law of God written on every human
heart (ROM. 2:15). The classic form of the Hippocratic Oath stated the duties of a physician clearly on this point: “I will give no
deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary
to produce abortion.”131 But the moral obligation to care for our fellow sisters and brothers so that we “do not hurt or harm
our neighbor in his body, but help and support him in every physical need” does not require us to employ treatments that
are useless or cause needless suffering.
The commitment “always to care, never to kill” does not mean that we should eliminate all those who suffer or that
we glibly ignore their suffering. Instead, it requires that we find efficacious ways to mitigate suffering. Christian ethicists summarize the principle governing Christian compassion in realistic, not idealistic, ways. In the name of Christ,
we show compassion most when we maximize care, not when we merely minimize suffering. Indeed, if compassion is
the elimination of all suffering, we might achieve it by ridding the world of sufferers. This does not mean, however, that
we support needless suffering. While we will continue to cite the sufferings of our Lord and their benefits, that does not
require us to refuse remedies and analgesics that can make the suffering we are called upon to bear more bearable. Just as
Scripture speaks of endurance in the midst of tribulation, not apart from it, so it also teaches love that remains steadfast
through suffering.

127
“Gov. Lamm Asserts Elderly, If Very Ill, Have ‘Duty to Die,’” New York Times, March 29, 1984. Lamm’s view was endorsed by some ethicists, for example John Hardwig in “Is There a Duty to
Die?” The Hastings Center Report 27, no. 2 (1997), 34–42.
128

John F. Kilner, “Age-Based Rationing of Life-Sustaining Health Care,” Section 74 in Therese M. Lysaught, On Moral Medicine: Theological Perspectives in Medical Ethics, 3rd ed. (Grand Rapids:
Eerdmans, 2012).

129

John T. Pless, Mercy at Life’s End: A Guide for Laity and Their Pastors (St. Louis: The Lutheran Church—Missouri Synod, 2013), 13.

130

The Ramsey Colloquium, “Always to Care, Never to Kill,” 45–47.

131

“Hippocratic Oath,” Encyclopædia Britannica, Encyclopædia Britannica, Inc., britannica.com/EBchecked/topic/266652/Hippocratic-oath.

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3. Irretrievably Dying vs. Terminally Ill
One may suffer from a condition the physician labels “terminal” without facing imminent death. Some prostate cancers
may grow so slowly that eventually a different malady actually causes death. Doctors may then elect to treat such a cancer
with benign neglect, since the consequences of the cures may be worse than the reasonable expectation of death in the near
term. The fact remains that such a person has a “terminal disease” or a “terminal condition.” However, that in and of itself
does not fix an expiration date on the person’s life.

for the patient and reducing the distress of family members. Since unwelcome symptoms exist on a spectrum from easily
remedied to the most unmanageable, “palliative sedation” (PS), as defined here, denotes the intentional lowering of awareness toward pain, perhaps including unconsciousness, for patients with severe and unmanageable symptoms. Although
being conscious and present to interact with family and friends remains a value that most people seek to retain as they near
the end of life, for some the relief of symptoms may outweigh the desire to be conscious.

Other people are irretrievably dying, and their body has begun to shut down.132 Family members may be advised
that a vital organ has begun to malfunction in a life-threatening way. Often efforts to shore up the function of one organ
(e.g., the heart) will create additional problems for another one (e.g., kidneys). Some forms of advanced disease may be so
progressed that only hours or days remain. Someone who is irretrievably dying may find few treatments that can be called
“useful.” Here the Christian duty of maximizing care comes into play.
4. Intention or Aim of an Action vs. Result of an Action
Elsewhere in this report, we cite the distinction between a “suicide mission” and an “act of suicide.” The first does not aim
at death; it is merely doing one’s duty as a soldier. The second intends for the act to produce death. This can be true even
when another agent may be involved. The so-called “death by cop” scenario describes a situation where a person uses a gun
to provoke the police to respond with deadly force. Here, we say that the person was committing suicide by another’s hand.
Polycarp submitted to the death of a martyr; he did not aim to die. Sometimes legitimate medical treatments will result in
death notwithstanding the care with which they are employed. A lifesaving but delicate surgery may lead to an unhappy
outcome contrary to the wishes of the patient, family and surgeon. More commonly, the use of pain medication may have
undesired side effects that are well known to the administering physician. We earlier noted that morphine effectively dulls
unrelenting pain so that some call it a “godsend” to sufferers. Unfortunately, it also suppresses respiration and may result in
death. However, pain relief and not death was the intention. Ethicists call this the “double effect” doctrine.133
Wesley Smith’s Culture of Death deals with the operational reality of “double effect” as it applies to the care for the
suffering. He cites attorney and ethicist Rita Marker’s four guidelines:134
1. The action taken (in this case, treating pain and relieving suffering) is “good” or morally neutral.

In some circles, this has been quite controversial. Imagine two scenarios. First, a dying patient suffers extreme pain
for which there is no easy solution. The physician gradually increases the dosage of morphine until the person can tolerate
the pain, even though it might also reduce the patient’s level of consciousness. Double-effect reasoning would support this
as a moral decision and good medical practice. But consider a twist to this scenario. What if the physician administers a
barbiturate drip intended to leave the patient unconscious? Here the goal is not to mitigate the suffering but to eliminate
the conscious experience in which the suffering is perceived. Does this constitute a treatment protocol that fails the moral
test because it intends an arguably evil effect (that is, permanent unconsciousness)? We might argue that surgeons render
patients unconscious routinely during surgical procedures. We call it anesthesia. But this argument proves too much. The
medication producing unconsciousness during surgery is both limited in duration and intended to allow repairs that will
restore the patient to health and return to somewhat normal function. The medication given to create a permanent state
of unconsciousness aims at an evil effect (if you consider consciousness an important value). Meilaender demurs on the
grounds that consciousness is not always a value that must or ought to be counted as supremely important. While we might
say that it would not be morally correct to put a healthy young person into a state of permanent unconsciousness, the same
might not be the case for a 95-year-old with hours left to live. Imagine that this elderly saint has prayed with her pastor and
bid each member of her family and family circle good-bye. Faced with difficult-to-manage pain, we might agree with those
who say, “Consciousness seems to me, if I may put it a little too brashly, not quite that big a deal.”136
6. Treatments Which May Be Refused vs. Care Which Should Never Be Denied
Elsewhere in this document the point has been made that one may reasonably and responsibly refuse treatment when it is
medically useless or excessively burdensome. The 1993 CTCR report proposed four factors to be considered as relevant for
withholding or withdrawing treatment:
(a) When irreversibility is established by more than one physician;

2. The bad effect (in this case, the possibility of death) must not be intended, but only permitted.

(b) When a moment in the process of dying has been reached where nothing remains for medical science to do
except to offer palliative care;

3. The good effect cannot be brought about by means of the bad effect.
4. There is a proportionately grave reason to perform the act (in this case, the alleviation of severe pain) and
thereby risk the bad effect.
135

5. Palliative Care vs. Palliative Sedation
Palliative care describes the treatment of the discomfort, symptoms and stress of serious illness. Whether offered in a
hospital or clinic, in hospice, or at home, the goal aims at relief from problematic symptoms such as pain, shortness of
breath, fatigue, constipation, nausea, loss of appetite and sleep difficulties, among others. Some palliative care seeks to
mitigate the side effects of medical treatments (e.g., chemotherapy). It holds forth the hope of improving the quality of life
132
Meilaender makes this distinction: “Irretrievably dying is not the same as to be terminally ill. One can be terminally ill but still expected to live for months or even years. For the patient who is
irretrievably dying, few if any treatments can really be useful.” Meilaender, Bioethics: A Primer for Christians, 85.
133
Widely credited to Aquinas, the doctrine of “double effect” has been much used in Roman Catholic moral literature. Protestants have sometimes employed the same idea by differentiating
intention from result.
134

Wesley Smith, Culture of Death: The Assault on Medical Ethics in America (San Francisco: Encounter Books, 2000), 106–107.

135

Perhaps the most useful and succinct summary of the ethical issues related to palliative sedation can be found in Meilaender, Bioethics and the Character of Human Life, Chapter 11, “Comforting When We Cannot Heal,” 121–132. This section relies heavily upon his points in that chapter.

(c) When possible treatment involves grave burdens to oneself and to others; and
(d) When there are no means left to relieve pain and no hope of recovery remains.137
While treatments may be refused, care must never be denied. Pless cites Wesley Smith’s observation that “Futile Care
Theory” has corrupted medical ethics such that some hospital protocols actually require that feeding tubes be withdrawn
from patients in a persistent vegetative state, even over the objections of family decision-makers and in spite of explicit
patient desires expressed in advance directives.138 Pless concludes that “a treatment may be refused or discontinued if it is
deemed futile, but care is never futile and is not to cease until natural death.”139
136
Meilaender, Bioethics and the Character of Human Life: Essays and Reflections (Eugene, Ore.: Cascade Books, 2020), 127. Meilaender allows that some cases may be more problematic. For instance, he balks at a blanket permission for palliative sedation where the patient’s suffering is not a result of an underlying physical pathology causing extreme and unendurable pain but a result
of feelings of loneliness, depression or disgust with the dependence occasioned by old age.
137

CTCR, Christian Care at Life’s End, 37.

138

Pless, Mercy at Life’s End, 12.

139

Pless, Mercy at Life’s End, 13.

2026 Convention Workbook