Introduction
The beliefs and policy statements of Lutheran denominations have rarely called upon the conscience of Lutherans to oppose the law. It is a strange experience, then, for Lutherans to live with the discord -- constrained though it may be for most people -- created by the passage of Oregon's Death with Dignity Act (DWDA) of 1994 (reaffirmed in 1998) that legalizes physician-assisted suicide (PAS). The Evangelical Lutheran Church in America's (ELCA) Message on End-of-Life Decisions (1992) explicitly opposes the legalization or practice of physician-assisted death (PAD) as "contrary to our Christian conscience." [1] Given this tension, and with the awareness that the Oregon bill might serve as model legislation for other states, the deans of the Oregon Synod introduced a resolution in 1998 calling upon the Division for Church in Society (DCS) to review the Message on End-of-Life Decisions and provide "recommendations and study tools for the Church, its Synods, and institutions. . . ."

The report is divided into four major sections and recognizes that readers may not find it pertinent to read every section:

• Terms and Moral Arguments Regarding Physician-Assisted Suicide
• Social Context and Overview of Factors Leading to Oregon’s Death with Dignity Act
• Living with Physician-Assisted Suicide in Oregon
• Observations and Summary Issues
• Appendixes
• Works Cited

This working paper stems from the DCS response to that resolution. It is based on a September 2000 visit to Oregon that drew upon the experience of the individuals and institutions there who have had to deal with these issues in order to cultivate insights into the legal, ethical, and institutional questions involved.* This working report, therefore, sketches theological and moral questions about physician-assisted suicide, but the fundamental purpose is to reflect upon what can be learned from the Oregon experience. This essay intends to explore rather than to argue and to describe rather than to prescribe. The goal is to surface questions and insights that will assist future reflection and action by those who consider or confront PAS.

* Those consulted included the bishop, synodical leaders, pastors, hospital chaplains, administrators of hospitals and senior care facilities, nurses, politicians, and activists. This consultation included representatives from both sides of the campaign involving the Death with Dignity Act of 1994.

Proponents of Oregon's Measure 16 (the 1994 ballot initiative) generally insist on the name "Death with Dignity Act," claiming that "physician-assisted suicide" imparts negative connotations. This working paper recognizes that all language "is loaded" but will use PAS as the primary term of reference for two reasons. Most important, the designation "death with dignity" is a much broader category that includes, for many proponents, broader convictions about euthanasia. Second, PAS is the specific procedure legalized in Oregon, as well as the relevant issue addressed in the ELCA message.

Terms and Moral Arguments

What is PAS?
As in most contentious public debates, the terms invoked in what is often called the death with dignity debate (DWD) are often ambiguously used and misused, a problem worsened by media sound bites. We must then indicate how the terms are to be understood in this paper as it attempts to represent the Oregon situation. Physician-assisted suicide (PAS) in Oregon is a legally defined set of procedures in which a doctor prescribes a drug for a terminally ill patient who then chooses when, or whether, to be the agent of his or her own death. The physician provides the means but is not permitted to be the agent of death.

PAS, then, is not identical with developments in the Netherlands, or with actions of Dr. Kevorkian and other proponents of active euthanasia. This distinction is consistent with biomedical literature in which PAS is generally distinguished from euthanasia.[2] The theological arguments are virtually identical whether the issue is euthanasia or PAS, but the moral and legal arguments must recognize some distinction. The primary one is, obviously, that of agency, and it is significant enough for some moral positions to affirm PAS while rejecting euthanasia. Despite such distinctions, it remains understandably difficult to keep PAS and euthanasia distinct in the public mind.

This ambiguity is exemplified in the Lutheran documents used in establishing or stating the ELCA position. The Lutheran Church in America's (LCA) Social Statement on Death and Dying -- the primary document establishing ELCA policy -- speaks of active euthanasia and defines it as "deliberately administering a lethal drug or otherwise taking steps to cause death."[3] The American Lutheran Church's (ALC) analysis paper on death and dying speaks broadly of "direct intervention to aid . . . a swifter death."[4] The ELCA Message on End-of-Life Decisions (MELD) focuses on physician-assisted death (PAD), and defines it as deliberately acting or authorizing an action to terminate the life of a patient. [5] In all these documents theological reasons overrule any moral or legal distinctions that some might use to justify PAS over against euthanasia.

The primary point in noting these distinctions here is simply to reinforce what the Oregon law is and is not. The law quite specifically authorizes PAS under certain conditions as described above. Euthanasia remains illegal in all states, including Oregon. Suicide itself is no longer illegal in any state, but all states except Oregon currently have some legal prohibition against assisting suicide, even for compassionate reasons.

The ambiguity of terminology is heightened by the inconsistent way that euthanasia (Greek for "good death") has been used. In much modern usage, and as followed in this report, euthanasia indicates the action whereby a person intentionally causes the death of another human being for compassionate reasons. [6] Euthanasia can be sifted into the categories of active or passive, voluntary, involuntary, or non-voluntary, depending upon criteria such as intent, patient competency, causation or assistance, and others. Physician-assisted suicide and voluntary euthanasia (when a patient asks another person to end his or her life) come very close to an overlap of meaning although they remain technically different because of the difference of agency provision of means in assisted suicide rather than immediate cause. We should note that the Netherlands' decision in 2001 is far more sweeping than PAS in legalizing several forms of euthanasia.

A Brief Overview of the Contrasting Positions,
on Christian Grounds
Although this working report focuses on the experience and practical questions garnered from the experience of Lutherans in Oregon, it seems important to begin by noting the arguments made by Christians on both sides of the PAS debate. (These can also be applied to most discussions of active euthanasia, as well.) We may note that these religiously based convictions will not always correspond to arguments made by people of other faiths or by those of nonreligious persuasion. The summary presented here may not include, therefore, all the issues argued in these debates, but it is fairly indicative. [7]  Appendix A provides greater detail regarding these positions.

Common convictions
Certain convictions are shared by Christians on both sides of the argument. The fundamental one is a common commitment to the sovereignty of God and to life as good in relationship to God's purposes. Both positions want to protect human dignity and both stress compassion toward those who suffer intolerable physical pain and immense emotional suffering while dying. Both positions lift up principles of social justice as critical issues in this debate. Finally, both recognize that situations of dying often create conflicts between the goodness of physical life and other goods or purposes in life. The differences that put individuals on opposing sides seem to result from:
a) different priorities for and judgments about these formal convictions;
b) different understandings of such concepts as autonomy and caring about others; and
c) differing convictions that figure into each side's thinking. A prime example of the last is the practical question of whether adequate safeguards can be built into the legal regulation of PAS.

Pro
Those who argue for PAS seem to give priority to two basic claims: [8]
1) the obligation to respect the autonomy of the dying, and
2) the obligation to relieve extreme pain and suffering. Other considerations, however, are also emphasized. These include the development of dehumanizing technology, the belief that "letting die" and "causing death" are virtually equivalent, and quality of life issues. Proponents often argue that modern commitments to self-determination, human dignity, and compassion require exceptions to traditional prohibitions against killing or suicide for compassionate reasons. They judge that in a technological society such as ours the ultimate Christian criterion must not be the maximization of physical life, but the realization of values.

Con
Those who oppose PAS, or various forms of euthanasia, seem to argue on the priority of:  [9]
1) God's purposes for life,
2) the communal nature of human life, and
3) the meaning and role of suffering. They recognize the factors of contemporary culture that fuel interest in PAS, but do not believe these justify the rejection of long-standing and fundamental objections to suicide or killing. For example, they hold that the integrity of physician-patient relationships depends on a sole allegiance to care and healing that never takes life. They argue that there is a genuine distinction between "letting die" and "causing death." They believe practical considerations against PAS are insurmountable -- considerations such as the pressures it produces on the critically ill to justify remaining alive, abuse to the elderly and vulnerable, and the difficulty of regulation.

With these positions in mind, we focus now on the specific story of Oregon's Death with Dignity Act.

Context and Narrative

Motivating Factors
The Oregon law -- as well as other developments around the death with dignity movement -- represents a fundamental reversal of religious convictions, medical practice, and the moral teaching of hundreds of years in a wide array of civilizations. (This is not to argue that it is universal.) This reversal is drastic enough that it should prompt the question: What is happening culturally that causes many people to even consider such a fundamental reversal? Some of the significant cultural factors that are often cited in the literature are enumerated below in an incomplete but representative list. A bit of reflection about this list recognizes that most of these factors have brought benefit to human life even while contributing to the contemporary forces that lead some to reverse historic prohibitions. It is, it seems, the compounded effect of the negative side of these factors -- experienced most frequently in the dying of friends and family -- that creates sympathy for PAS arguments.

The significant cultural factors include at least:
1. The culture's commitment to autonomy or individualism, often in extreme forms.
2. Shifts in religious and moral sensibilities. These result from many factors, from the privatization of religious belief to the removal of suicide from the list of unforgivable sins. These factors certainly include the receding authority of religious prohibitions and the growing influence of nonreligious sources such as the media on moral formation.
3. Growing pluralism and an accompanying tolerance for "it's up to each individual."
4. The growing emphasis on patient self-determination and rights.
5. The development of medical and technological powers that permit unprecedented control over when and how the human body dies.
6. The extended length of the human lifetime and the related fears of being a burden on a family's financial and emotional resources.
7. The institutionalization of dying.
8. The financial cost of dying.
9. The inadequacy of pain relief and pain management. [10]
10. The transformation of the physician-patient relationship from a personal one to an economic one.

Several observations related to these factors:
a) The first three are more general descriptions of cultural trends. The last seven are specific factors mentioned often in the literature. [11]
b) These cultural factors can act as both accelerator and as brake on public sympathies for DWD legislation when they change or are addressed. This is suggested by the pull back of advocacy for PAS due to improved pain management or improved hospice care.
c) The categories of ways of "dying" that people fear may be distinguished as: extended in time, physically excruciating, emotionally isolated, burdensome, undignified, and expensive. These individual descriptions are generally combined in discussions of PAS, such as: "If you're in pain, it's a very frightening thing and it's very alone, . . . I don't want to be dependent on anybody or use up my family's resources." Such statements represent the fears that have found political expression in the "death with dignity" (DWD) movement.

An Overview of the State of the DWD Movement
One way to date the origin of the DWD movement is with the establishment in 1980 of the Hemlock Society, the oldest and largest death with dignity organization in the U.S. [12] The link between this movement and the patient's rights movement is indicated by the name of Hemlock's legislative arm, the Patient's Rights Organization. DWD organizations working with like-minded activists have been successful in putting initiatives on ballots in several states including Washington (1991), California (1992), Michigan (1998), and Maine (2000). Some of these initiatives have failed by relatively close margins and the vote on Oregon's Death with Dignity Act (DWDA) was also close, passing in 1994 by a vote of 51 percent to 49 percent.

Oregon's 1994 DWDA was challenged in the courts and was not implemented in 1995. In 1997 the Supreme Court reviewed several appeals related to PAS -- not including Oregon's -- and its subsequent ruling cleared the way for states to permit and regulate physician- assisted suicide, but upheld the constitutional right of states to have laws opposing it. The Court's position was that PAS should be a matter of public debate and decision rather than a matter of either inherent constitutional right or prohibition. The Court held also that the distinction between letting a patient die and causing a patient's death is an important and logical one well established in U.S. history and legal tradition. [13] It should be noted that this aspect of the Court's decision concurred with a central emphasis of the ELCA's Amicus Brief filed as part of that case.

Opponents of PAS in Oregon, including the religious coalition of which the ELCA's Oregon Synod was a part, successfully used the interim provided by legal challenges to place a referendum on the DWDA onto the Oregon ballot in the fall 1997. It failed by a margin of 60 to 40. Observers generally believe that this margin of defeat did not indicate significantly greater support for PAS, but rather served as a referendum on several tangential issues. One such issue was a message to legislators about the Initiative process, that is, a second initiative was not appropriate since the voters had spoken in 1994. Another factor included the stiffened resolve of Oregonians around state's rights. Voters perceived federal efforts to counter PAS (see next paragraph) as an attack on their state's rights. Finally, voters seem to have been antagonized by the heavy-handed tactics of opponents to PAS, tactics that were perceived to smack of religious authoritarianism and fear mongering. The campaign against DWDA focused its attack by using messages devoted to emotional appeal. One prominent campaign ad, for instance, promoted the idea that patients who attempted physician-assisted suicide would often vomit up the pills and be worse off. [14] In any case, the voters' 1997 rejection of the referendum coupled with the Supreme Court's ruling permitted Oregon's Death with Dignity Act to become law on January 1, 1998. Several amendments since then have clarified the bill's language, but have left its substance untouched.

Politically speaking, the DWDA is a settled matter in Oregon and activists have targeted their energies on other states. Examples include the ballot initiatives in Michigan (1998) and Maine (2000). The voters' rejection in these two states along with the fate of California's Death with Dignity Act is perhaps representative of the condition of the DWD movement. A bill comparable to Oregon's DWDA caused a public stir in March of 1999 when it garnered enough votes to advance out of California's House Appropriations Committee. It was then placed by its author in the inactive file, presumably because of a lack of votes, and was officially declared dead on February 3 of 2000. [15] No effort to revive it appears probable, at this time.

At least some of the erosion of support for DWD legislation since 1994 is due to opponents' countermeasures addressing the cultural issues mentioned above. One example is the Federal Assisted Suicide Funding Restriction Act signed into law by President Clinton in 1997. It prohibits use of federal funds to support PAS. Such measures, as noted above, are perceived as chipping away at the range of Oregon's decision for PAS. Another is the pending federal legislation known as the Pain Relief Promotion Act (PRPA) that appears to be gathering momentum at the time of this writing. Many observers believe its passage will largely mute additional momentum for PAS in other states. The Act promises greater latitude for physicians to manage pain for terminally ill people without legal jeopardy; such latitude seems to correlate with less willingness on the part of physicians to cooperate with assisted-suicide requests. [16] The relation of the PRPA to PAS is clear in the bill's own text, which indicates its purpose as amending "the Controlled Substances Act to promote pain management and palliative care without permitting assisted suicide and euthanasia and for other purposes."

The Oregon Law
Statute #127, the statute authorized by the 1994 DWDA, states that Oregon residents older than 18 with terminal illness (defined as death expected within six months) who are mentally competent and physically capable may receive a prescription intended for suicide. (It should be noted that this law by default confines participation to those able to use their hands.) The procedure is carefully spelled out: a verbal request to a doctor (no doctor or health care system is required to participate) is the first step and that must be followed by a mandatory fifteen-day waiting period and a written request witnessed by two non family members. Following receipt of a written request, the prescribing physician involves a consulting physician in determining whether the patient is competent. If either physician believes the patient's judgment is impaired by a psychiatric or psychological disorder such as depression, the patient must be referred for counseling. The prescribing physician must inform the patient of alternatives to suicide, such as comfort care, hospice, and pain control measures. The physician must request, but may not require, the patient to notify next of kin. Presuming these requirements are met and that forty-eight hours have passed since submission of the written request, the physician then prescribes tablets from a participating pharmacy (non-participation is built into the law) and must report the prescription to the Oregon Health Division. The patient receives the medication with specific instructions for self-administration and it may be used at their discretion.

The ELCA's Message [17]

Overview
The contemporary dilemmas around dying plus the ongoing political debate prompted an ELCA Church Council decision in 1991 to address several end-of-life issues. This was done in a message adopted by the Council in November of 1992 under the title A Message on End-of-Life Decisions (MELD). Such messages represent the stated position of the ELCA on specific issues because they apply principles established in ELCA social statements (the highest level of social policy). MELD is based on the 1982 LCA's (an ELCA predecessor body) social statement Death and Dying and is consistent with the 1977 analysis paper on Death and Dying of the ALC (another predecessor). MELD's stated purpose is to address "some timely aspects of end-of-life situations and encourage further deliberation on the topic throughout this church" (p.1). In other words, it intends to offer guidance to ELCA members, families, care givers, pastors, social ministry organizations, and advocates, as well as to contribute to the public discussion.

The message begins by acknowledging the "dreaded context for dying" of burdensome cost, isolation, and lack of autonomy that sometimes attend the achievements of modern medicine. It then presents key aspects of Christian commitments that have undergirded thinking about end-of-life issues. It sets forth key convictions such as: life as a gift from God, respect for life's integrity, the centrality of community in human life, and the meaning possible even in times of suffering and adversity (p.2). The message also recognizes and affirms the contemporary political emphasis on the rights of patients as expressed, for instance, in advance directives. It acknowledges the ambiguity of end-of-life decisions that must be shared by patient and family or friends and encourages proactive development of palliative care. Under the general heading of "Allowing Death and Taking Life" it addresses specifics in three subsections: Withholding or withdrawing artificially-administered nutrition and hydration, Refusal of beneficial treatment, and Physician-
assisted death. The first two are distinguished from the last according to the distinction between "allowing to die" and "taking life."

The position on PAD
The MELD's sub section dedicated to PAD begins by noting that an emphasis on patients' rights and the emergence of disease processes -- such as Alzheimer's -- that threaten dramatic loss of human capacities are "a few of the realities that have converged to create an environment where some patients ask that their life be ended"(p.4). It then asks whether it is ever "morally permissible for a physician deliberately to act or authorize an action to terminate the life of a patient?" (p. 4). In answer it states, citing the predecessor LCA statement, that "As a church we affirm that deliberately destroying life created in the image of God is contrary to our Christian conscience." Such a statement invoking conscience represents one of the strongest ways possible in which Lutherans can state a moral position. [18] This vigorous assertion is immediately correlated with a statement that recognizes how health care professionals sometimes struggle personally in situations when pain "becomes so unmanageable that life is indistinguishable from torture." Nevertheless MELD, in the next paragraph urges opposition to the legalization of PAD of any kind. The rationale used there mentions the prohibition against "private killing," the impossibility of public regulation, and the potential for abuse. In the final paragraph, it calls upon physicians to engage in aggressive management of pain even when that may result in an earlier death. It suggests that hospice care and a more equitable health care system should be a priority for those concerned about end-of-life decisions.

Conclusion
The document as a whole concludes with a section on "Ministry in preparation for the end of life." This section encourages the use of advance directives and calls upon congregations and church-related institutions to provide for education and deliberation on these matters. It celebrates pastors and communities of faith that aid dying people with ministry. It concludes with a reminder of the God-given mystery of both life and death and the Gospel's promise of eternal life (p.5).

Living with PAS in Oregon

The Oregon law often is seen as a de facto social experiment, and it leads naturally to several questions: What has been the experience with PAS in Oregon? What has been the experience of Lutherans in Oregon? What may be learned?

Reports on the Practice of PAS in Oregon
Three years of reports and assessment are available presently from the Oregon Health Division Center for Disease Prevention and Epidemiology (OHD) of the Department of Human Services. The Center bears responsibility for monitoring the practice of the DWDA.[19] According to these three reports 70 persons have died under DWDA (16 in 1998, 27 in 1999, and 27 in 2000). This number represents an average of eight out of 10,000 Oregon deaths per year. The consistently notable demographic characteristic is that those individuals using PAS tend to be significantly better educated. Other factors such as gender, race, marriage status and so forth appear to be statistically insignificant. [See Appendix B] These findings seem to contradict assertions by those on both sides of the PAS issue. Opponents cannot point to evidence: a) that patients have rushed to use assisted suicide in a widespread manner; or b) that the poor and most vulnerable groups in society will receive PAS in place of palliative care. Proponents, on the other hand, cannot support their contention that unmanageable pain plays a major role in motivating patients to use PAS. The reports indicate, rather, that patients are motivated most significantly by fears of lost autonomy, bodily function, and participation in activities that make life enjoyable. [20]

Several caveats must be attached immediately to these statements. The first is to note the statistically brief period represented. Secondly, there is debate on the conclusions publicized by OHD interpreters. A Hastings' Center article, for instance, questions whether any conclusions can be drawn based on a reporting process that involves self-reporting and has no built-in verification method. Under such circumstances it questions, for instance, how the report can assert that patients who were assisted in suicide were receiving adequate end-of-life care. [21] It appears, then, that the reports from three years of PAS are interesting and worthwhile, but cannot determine how well the regulation of PAS will really work.

Proponents of the DWDA indicate satisfaction with the general way in which PAS has been conducted within Oregon. No obvious abuse has been reported, and the public reaction has been calm. A kind of quiet acceptance seems the norm. Questions about PAS to local residents generally elicit a response such as, "Yes, I know PAS is the law, but I don't really know much about what it means." A generic statement of being for or against it then follows this disclaimer. Many in Oregon do know that their situation is being watched nationally, as indicated by the featured role of Oregon's situation in Bill Moyers's September 2000 series entitled "Dying in America." In this vein, opponents have raised red flags not so much about the abuse of the law but about subsequent developments. As examples, they point to the "How-to-PAS" video that aired on television and to the attempt to provide Oregon Death Stamps (like food stamps) as a way to make the procedure affordable for everyone. These opponents of PAS argue that Statute #127 is creating an environment in which assisted suicide becomes routine and is slowly numbing public sentiment to the value of life.

The Synod's Experience
General
During the campaign of 1997 against DWDA, synod opposition took the form of an open letter to congregations that stated the ELCA position and encouraged DWDA's defeat. The synod had representation on the anti-PAS coalition but did not allot any financial support to the effort. The ELCA Message on End-of-Life Decisions itself was hailed on the floor of the Oregon Legislature (by a non-Lutheran) as a well-balanced and intelligent religious message. In addition, respect grew for the ELCA during the campaign in several quarters because of the advocacy carried out by ELCA people on this issue.

Since 1997 the church's relation to the DWDA might be characterized as coping. The primary sense is that the political process has run its course and it is time to get on with other issues. There has been little activity of any form on the issue at any level within the Oregon Synod. Synod and congregational energies are dominated by other, more immediate concerns. This is not nonchalance, but a kind of resigned acceptance that appears to represent an attitude of "must learn to live with it."

The experience of the Oregon Synod suggests once again how poorly prepared the church is on biomedical issues. Even in 1994 and 1997 there appears to have been only minimal attention in congregations to the issue of PAS in general and to MELD in specific. This observation should not be surprising. Pastors have had little education about or opportunity for theological reflection on these matters. Congregations are not accustomed to talking together about tough social issues and such conversations are often avoided because they can become mired in intellectual confusion and emotional responses that are troubling and upsetting. The application, for instance, of the standard moral distinction of "double effect" for the use of morphine in terminal cases or the difference between "letting die" and "taking life" seems like a foreign language to many. Conversation with those in Oregon indicated, further, that those who had experienced a loved one's agony while dying were hesitant to accept the ELCA's absolute position. Given such factors, there was and is little motivation to encourage moral deliberation on PAS.

MELD in Oregon
The synod's experience with MELD as a tool for moral deliberation seems mixed. Pastors expressed reservation about it on two counts. The first involves confusion as to its authority. A common view is that, after all, "It is only a message" and this seems to dilute any sense of its authority. The message, of course, simply specifies ELCA policy established by the LCA's statement on Death and Dying. This relation, however, between MELD and that policy position is not clear in the minds of many church leaders or members. The second reservation regards its internal clarity. Church leadership understands that the message opposes physician-assisted death, but their comments indicate that the message is considered limited in its address and in its persuasive appeal. It can be pointed out that the message doesn't speak directly to assisted suicide but rather to euthanasia and the "deliberate action of a physician to take the life of a patient." The message's primary address is to the physician and medical community and little is said, directly, to the patient or family members. As one person pointed out, the provision of means for suicide and the action of mercy killing are morally different in some people's minds since the former simply gives patients a choice. The message's opposition to the choice of assisted suicide is implied but never directly spelled out. Pastors indicated it had been difficult to use MELD in congregational settings for such reasons.

In response, one might ask whether such conversations included attention to ELCA source documents, such as the LCA statement that does contain more detail. The disconnection in the minds of church leaders between the message and the social statement would suggest that this line of response was not followed. Whatever the merits of this reservation about the message as a tool for moral deliberation, leaders in Oregon express a wish that additional material be made available. They believe these materials could build on the ELCA message and its sources through elaboration, interpretation, and clarification.

Oregon's vote as an indictment
A final observation is that many in Oregon sense that the vote represents a kind of indictment of the church's ministry. On one level, this could be interpreted as an indictment of its evangelism and outreach. Oregonians often mention that the success of the DWDA may well have occurred there because it is the least "churched" state in the union. One cannot help but wonder, though, if the indictment doesn't operate at a different level as well. The public motivation for PAS is clearly the fear of pain, meaninglessness, and loss of autonomy associated with dying. The implied indictment is that the church has not prepared its own people to "die well" by drawing upon the resources of faith. Traditional Christian practices for the good Christian death, such as liturgies for the dying, the use of lamentation psalms, practices in the "remembrance of death," and others have been neglected in the Lutheran tradition, as in many denominations. Other forms of aid in dying, such as structured community support, have been haphazard. Christians therefore, like the rest of our culture, have become dependent on the offerings of medical technology as the primary resource for facing death. This fact has left those inside the church, as well as those outside, without a range of resources to counteract the appeal of PAS. In these ways, the vote in Oregon and the experience of the church there can be understood as an indictment. If recognized, the situation in Oregon could become an opportunity to develop attention to bioethical questions and to reclaim pastorally the Christian practice of dying well. Such resources would provide a unique countermeasure to the fears of meaningless and technologically sterile dying.

ELCA-Related Institutions
Whether or not the church will understand the Oregon vote as an indictment, the medical community clearly talks in those terms. [22] This recognition, in tandem with other factors, has prompted the Oregon medical establishment to respond with intentional efforts to improve care of the dying. One example is the "Comfort Care Initiative" of the Legacy Hospital system (a large system in Portland with traditional, if loose, connections to the Lutheran community). The Initiative is exploring such possibilities as comfort care teams and aggressive palliative care, all guided by the belief that no patient needs to suffer excruciating pain in this age of sophisticated medications and technology. The state of Oregon is also becoming recognized as a leader in the quality and availability of hospice care, efforts stepped up since 1994. In these ways the medical system points to what could be a constructive insight: "A good offense is the best defense." That is, be proactive about the concerns that motivate voters to support DWD measures.

The experience of church-related institutions in Oregon also can be instructive. The passage of DWDA left public institutions like hospitals and nursing homes with the need to determine their institutional policy about cooperating with PAS requests. The awareness of MELD heightened the question in institutions with affiliations to the Lutheran church, ties of finance, tradition, or board membership. The question was asked in several institutions, at least internally, as to the ways they were bound by the MELD position and what consequences would ensue if it was disregarded. The ELCA's document on Policies and Procedures of the Evangelical Lutheran Church in America for Addressing Social Concerns indicates that "ELCA-affiliated agencies and institutions will develop policies and practices consistent with the principles and directives of social statements" (p. 13). There are, however, no mechanisms of enforcement and no guidelines as to what this means in any specific instance.

The spectrum of options that Oregon agencies have developed around PAS is instructive. We shall label them "stances" for simplicity's sake. Stance 1 insists on complete non-cooperation with patients who request PAS. Stance 2 does not permit PAS on an institution's premises, but will cooperate in moving a patient to an alternative location. This response usually involves initiation of a counseling process to help the patient think through their initial request. Stance 3 is a variation on number two in that it does not permit any house staff to be involved, but patients are not required to be moved. PAS can be carried out on the premises. This option is justified by appeal to patient care and comfort. Stance 4 would allow both the use of the site and the participation of staff. It appears, according to those persons consulted, that Lutheran-related institutions have adopted some form of positions two or three.

It appears, also, that ELCA-related Oregon institutions did consider ELCA policy and the MELD message in their deliberations. At the present time, informal assessment suggests that their policies seem to be in general compliance and the question of strictures is mute.

Concluding Observations

1. Whether Oregon's DWDA will prove to be the first of many such laws or simply a kind of one-time social experiment remains unknowable. The trend toward improved pain relief and better palliative care -- expressly encouraged by the medical profession -- as well as the continued failures of recent DWD legislative efforts suggest that the momentum for PAS may be ebbing at the time of this report. In any case, two points are clear. First, public concern on these issues remains significant and the forces fueling critical mass for PAS are still present. Unless public concerns about dying are successfully addressed, a resurgence of support for PAS or euthanasia is always possible. Second, the pluralism and growing nonreligiosity of contemporary culture makes more probable additional conflicts between church policy and state law. What can be learned from Oregon will likely be applicable to other public issues.

2. The events in Oregon can be understood as a kind of indictment. It was an indictment on the health system for its failure to provide adequate palliative care and to rein in the use of dehumanizing technology. It was an indictment of physicians insofar as they failed in the assertive use of pain relief and end-of-life care. It was an indictment of the church for its abandonment of the care of the dying to the forces of modern medicine.

3. The evaluation of the ELCA's End-of-Life message in the Oregon experience suggests that it was a valuable tool, but not an optimal one. We can assess this from three angles.

As a political tool: MELD was hailed politically, as noted above. It seems, however, that synodical efforts could have made more use of it. For example, a public statement based on the message, such as was done in Michigan in 1998, would have been politically valuable. It is reasonable to ask, also, whether a financial and more visible public commitment to the DWDA might have been in order on the part of the synod. Any efforts to discuss PAS using MELD within the congregations during the Oregon campaigns should be commended, but certainly such efforts could have been more extensive. Such discussions are integral in equipping Lutherans to practice faith-based citizenship.

As a tool for moral deliberation: MELD has value for deliberation and moral education, but a clear desire exists for a more finely honed tool. Some of the shortcomings reported above clearly rest with the general poverty of understanding about ELCA social statements and messages. The lack of preparation and interest on the part of pastors to deal with biomedical issues bears some responsibility for the difficulties cited. The concrete suggestion from Oregon for additional study materials, however, seems appropriate, especially if the church were to be involved in future PAS debates.

Given the reservations about MELD as a deliberative tool, a few reflections on how the message might have been more helpful seem appropriate, primarily as suggestions for future messages. It is, of course, easier to make such observations in retrospect.
a) The message should be applauded for addressing directly the questions about the "taking of life," but it seems that a broader stroke including PAS and all forms of active euthanasia would have made the document more relevant. This suggestion seems in keeping with the intent of the 1984 LCA statement that headlines active euthanasia, and with the general rationale for the message. [23] The question asked in MELD's paragraph #1 of the PAD section, for instance, could have been something like: "Is it ever theologically and morally acceptable for anyone to authorize means or to terminate a human life -- including his or her own -- for reasons of mercy? The framing of answers to that question would have lengthened the document only a paragraph or two, but would have added clarity and been more widely applicable. The emphasis in the message on the physician-patient aspect is too heavily weighted even though critically important. The strong claim regarding Christian conscience in paragraph #2 is an example. That claim is embedded in language addressed to physicians and presumably the medical community, but surely it applies to family members, patients, and others. Its broader application is implied, but seems opaque. The experience in Oregon seems to demonstrate the need for more comprehensive and clearer language.
b) Paragraph #4's rationale could have been stronger if it specified several principled objections, beyond the reference to "private killing," and had been lengthened slightly. References to the difference between allowing death and taking life, stewardship of life, and other convictions could have been stated here as rationale. Their inclusion would simply seem more persuasive. Readers are likely to hone in on paragraph #3 and #4 and their attention in those paragraphs is drawn to the practical issues that may or may not prove durable arguments.
c) The message should be commended for clearly addressing the need for better palliative care and pain relief. Perhaps more could have been said that would have spoken to prominent public fears, fears such as the loss of control and the indignity of dependence. Such an address might, for instance, urge acceptance of the limits of human autonomy in the hope and meaning Christians find possible even in times of suffering and adversity.
As a tool for guiding institutional policy: The matter of the message's authority remains unclear to those in Oregon. General efforts are needed to correct the notion among pastors and lay leaders that "it's only a message." Additional clarity is also needed on the authority that ELCA messages have for SMOs. This need may be mostly a matter of communicating what is already stated in the ELCA procedural document, [24] but it seems fair to suggest that more reflection on the question would be helpful. This issue will arise again if another state were to adopt DWD legislation.

4. If the church were to build on its strengths in addressing the broad social milieu that gives rise to PAS initiatives, several suggestions seem obvious. These can be listed under three headings: institutional, intellectual, and spiritual.
Institutional: The church's institutional response could include encouraging and supporting the role of public advocates. This would mean, for instance, official ELCA efforts on behalf of the Pain Promotion and Relief Act pending in Congress. Such action seems warranted by MELD. As suggested above, further institutional reflection also seems needed on the status of messages for church-related institutions. Finally, institutional initiatives on the practice of dying well would build on one of the unique strengths the church can offer to a culture that fears the way people experience dying.
Intellectual: The church would benefit from providing additional efforts and tools for moral deliberation [25] in addition to publicizing currently available ones including those of denominations with whom we share Eucharistic agreement. Additional efforts at several levels could promote better intellectual and pastoral preparation. Obvious examples include more offerings in seminaries on biomedical ethics, or attention to the cultural dominance of rights language within Christian congregations to the exclusion of the Christian moral language that is grounded in relationships. [26] Finally, the Oregon experience should prompt reflection upon the church's relation to culture and to what extent the church may need to be counter-cultural in the contemporary social context.
Spiritual: The church's spiritual tasks are, of course, harder to specify and include efforts in every dimension of the church's life. However, we can specify attention to the role of Christian formation and Christian conscience as obvious recommendations flowing from the language of MELD. These would strengthen understanding of the message and prepare church members for conflicts between state law and church policy. Finally, to repeat the above, the spiritual task includes reclaiming Christian resources and practices that better equip Christians to die a good Christian death.

Appendix A

Note: The order of these arguments is intentional and indicates contrasting priorities.

DWD proponents tend to argue on the basis of:
1. Human choice: Respect for autonomy or self-determination as central to human dignity necessitates the option of PAS.
2. God's purposes:

a. God's purposes and sovereignty would still be honored by this exception. As in "just war" thinking, the necessity of killing overrules objections that are normally legitimate.

b. PAS is an appropriate moral response to pain and suffering because it permits individuals to avoid agonizing and dehumanizing situations. Christian faith does not require intolerable suffering without release.

3. The impact of contemporary medicine:

a. PAS is a way of curbing the unrelenting power of medical technology.

b. PAS, as with the withdrawal of treatment, can be legitimated because patients and physicians are under no obligation to prolong physical life through disproportionately burden- some treatment.

c. Physicians may appropriately participate in PAS because they have a duty to provide comfort when the end of life is unavoidable and nothing else can be done.

4. The social context:

a. The dangers of PAS to public life can be overcome with careful regulation.

b. Precautions can be taken against financial coercion to choose PAS.

PAS opponents tend to argue on the basis of:
1. God's purposes:
  a. God's purposes and sovereignty are impeded and violated if PAS is condoned. A person's life is a gift and is not his or her own to end. The possibility of properly weighing such consequences is not within human power and it is a matter of accepting human limitation to let other factors end life.
  b. Some pain and suffering are inevitable in life. Its inevitability is, however, a call to alleviate it with appropriate means that sustain life. Further, we must never forget the possibility that God can use suffering in surprisingly redemptive ways.
2. About human choice:
  a. Christian moral constraints on autonomy argue against PAS. God's creative and loving purpose for human beings is the ultimate source of the inviolability of human life, not autonomy. The fact that a choice for death exists does not make the choice right, even in extreme circumstances.
  b. The availability of PAS creates a momentum against the choice to remain alive without justifying one's existence.
3. The impact of contemporary medicine:
  a. The appropriate treatment of pain and suffering would decrease requests for PAS. We must listen to experts in pain management and palliative care who insist that available measures could relieve the pain and suffering of almost all dying persons, no matter how extreme.
  b. The role of the physician is to heal, not to assist in killing. The integrity of the physician- patient relationship is rooted in just this trust. Assisted suicide by definition cannot be part of a "healing process" or one that enables individuals to die well.
  c. Other means are available to respond to the dehumanizing use of medical technology. Hospice care, advance directives, and the like are alternatives that better respect the gift of life. Further, and ironically, modern medication for suicide is really another form of a technological fix.
4. The social context:
  a. PAS encourages individual abuse. Such activity is difficult to regulate and abuse is a reality in any human activity. For instance, individuals may be or feel pressured, consciously or otherwise, to end their lives for financial reasons.
  b. If we legalize PAS, why not legalize forms of euthanasia that can be defended by the same principles. For instance, if the warrant is to relieve suffering, then no reasons exist to limit the practice to those who are competent.
  c. The social isolation of the dying, as well as the elderly and those with some disabilities, may lead them to choose PAS. It offers a quick exit from a world in which human affection and care are lacking. PAS would be the final act of isolation from others for those who can no longer live self-contained lives.

(The skeleton of these outlines is found in Epis. Diocese of Washington Committee on Medical Ethics, Assisted Suicide and Euthanasia: Christian Moral Perspectives, but the adaptation and the descriptive emphasis belong to the writer.)

Appendix B

This table is copied from Oregon Health Division Center for Disease Prevention and Epidemiology Department of Human Services, Oregon’s Death With Dignity Act: The Second Year’s Experience (23 February 2000).

Works Cited

Committee on Medical Ethics, Epis. Diocese of Washington. Assisted Suicide and Euthanasia: Christian Moral Perspectives. Harrisburg, Pa.: Morehouse Publishing.

Department of Human Services, Oregon Health Division, Center for Disease Prevention and Epidemiology, 2000.

Department of Human Services, Oregon Health Division Center for Disease Prevention and Epidemiology. "Oregon's Death with Dignity Act: Three years of legalized physician-assisted suicide." February 2001.

DuBose, Edwin B. Physician Assisted Suicide: Religious and Public Policy Perspectives. Chicago: The Park Ridge Center, 1999.

Evangelical Lutheran Church in America, "End-of-Life Decisions." (1992):1992.

"Policies and Procedures of the Evangelical Lutheran Church in America for Addressing Social Concerns." (1997):1997.

Foley, Kathleen, and Herbert Hendin. "The Oregon Report: Don't Ask, Don't Tell." The Hastings Center Report 29, no. May-June (1999).

Jersild, Paul. Spirit Ethics: Scripture and the Moral Life. Minneapolis: Fortress, 2000.

Junkerman, Charles M. D., and David M. D. Schiedermayer. Practical Ethics for Students, Interns and Residents: A Short Reference Manual. University Publishing Group, 1998.

Lutheran Church in America, "Death and Dying." (1982):1982.

Schodolski, Vincent J. "Painkillers Deterring Suicides: Doctors Urged to Use More Drugs to Ease Plight of Ill." Chicago Tribune (Chicago), 21 February 1999, 1.

Task Force on Ethical Issues in Human Medicine, ALC. "Death and Dying: An Analysis." (1977): 1977.

Copyright © 2001, Evangelical Lutheran Church in America.
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