An Orthodox Christian Perspective Concerning Medical Bioethics
By Protodeacon Basil Andruchow
Introduction
The
understanding and discussion of contemporary medical bioethical issues is, for
Orthodox Christians, predicated on the tenets of the Orthodox Church. These
tenets help us to frame the right questions for consideration from the very beginning.
The first of these questions asks why humankind exists on earth. The following
statements reflect the teachings of the Orthodox Church in response:
- God created the world and all that is within
it.
- God created mankind, both male and female, in
his image and likeness. Mankind is considered sacred and is eternally precious
in God’s sight.
- We are called by God/Jesus Christ to live our
lives in a continuing state of becoming like God.
- We strive to be in union with God while on
this Earth with the expectation, hope and belief that we will be with Him in
life everlasting.
Within
this context, the concepts, topics, and issues of contemporary medical
bioethics must be carefully considered. What follows is a framework for
understanding the Orthodox Christian perspective as it relates to medical
practices and individual decision-making.
In 1992,
the Holy Synod of Bishops of the Orthodox Church in America issued its
affirmations “On Marriage, Sexuality and the Sanctity of Life”, which can be
obtained from the OCA web site, www.oca.org. Where applicable, a particular
relevant affirmation may be included in a particular topic section.
This
synopsis of some of the more important medical bioethical issues facing us
today as Orthodox Christians is not intended to be a complete presentation of
all the issues and topics nor should it be considered an official document.
Rather, it is intended to spark thought and discussion with regard to medical
bioethical considerations and decision-making.
BEGINNING OF LIFE
Conception
“God wills that men and women marry, becoming
husbands and wives. He commands them to increase and multiply in the
procreation of children, being joined into “one flesh” by His divine grace and
love. He wills that human beings live within families (Genesis 1:27; 2:21-24;
Orthodox Marriage Service).”
- 1992 OCA
Synod of Bishops’ Affirmations, “On Marriage, Family, Sexuality and the
Sanctity of Life”—The Mystery of Marriage
The
Orthodox Church teaches that ‘full personhood’ is present at the time of
conception, when the male sperm and the female ovum nucleus merge to form the
single, 46 chromosome, totipotential cell called the zygote. The zygote is a
biologically unique and complete individual. Following mitosis, or cell
division, the developing embryo moves down the fallopian tubes of the woman.
The fully developed embryo then attaches to the uterine wall, continues fetal
development and is subsequently born into the world. The understanding of and
belief in the ‘full personhood’ of the zygote, and thereby the embryo, dictates
our Church’s position with regard to abortion and certain aspects of stem cell
research.
Conception Control
“Married couples may express their love in
sexual union without always intending the conception of a child, but only those
means of controlling conception within marriage are acceptable which do not
harm a fetus already conceived.”
- 1992 OCA
Synod of Bishops’ Affirmations, “On Marriage, Family, Sexuality and the
Sanctity of Life”—The Procreation of Children
The
Orthodox Church does not support the general use of contraceptives for
conception control. The understanding of our Church’s position with regard to
contraceptives is based on the fact that a husband and wife form the basic
foundation of the family unit. Sexuality within a Christian marriage is a
blessing; the couple in love is expected to bring forth children who are the
fruits of the union of “one flesh.” A couple must be willing to accept the
possibility of pregnancy from this act of love.
On the
other hand, our Church understands that there may be some very compelling
reasons for the use of birth control measures. An example is the case of a
woman whose health and well-being would be severely jeopardized if she had a
child. Matters of this type have a very large pastoral component to them and
should be discussed with the couple’s parish priest.
In-Vitro Fertilization
“Married couples may use medical means to
enhance conception of their common children, but the use of semen or ova other
than that of the married couple who both take responsibility for their
offspring is forbidden.”
- 1992 OCA
Synod of Bishops’ Affirmations, “On Marriage, Family, Sexuality and the
Sanctity of Life”—The Procreation of Children
An
infertile couple may agonize over the fact that they are childless. In the
past, this was a fait-accompli. With the rapid development of medical fertility
science in the latter part of the 20th century and continuing to this day,
techniques have become available to assist childless couples in their efforts
to bear children, particularly through the method of in-vitro fertilization.
Essentially this method involves the fertilization of the wife’s ovum/egg with
the husband’s sperm in an environmentally controlled Petri dish. The resulting
embryos are allowed to develop to the stage just before uterine implantation.
Three to five of the most viable embryos are selected and placed in the wife’s
uterus with the hope of implantation and subsequent birth of a child.
While our
Church recognizes the potential benefits that may be derived by a childless
couple using the services of a Fertility Clinic, it should be noted that this
type of service is expensive and may not always succeed. Again, this is a
pastoral issue and the couple should discuss this with their parish priest.
There
are, however, other aspects of the in-vitro fertilization process, which may or
do run counter to our church’s teaching.
First of
all, it divorces procreation from the conjugal act and should not be considered
to be a normative practice. Yet, in-vitro fertilization could become standard
practice due to certain selective benefits mentioned below. The application of
this technology in some quarters has also allowed the use of surrogate mothers,
in some cases to relieve the wife of the burden of child bearing. The practice
of using or being a surrogate mother is expressly forbidden by our Church. As a
corollary to the above, it should also be stated that our Church expressly
forbids a female or male Orthodox Christian to sell their eggs or sperm,
respectively.
Second,
the process of choosing the most viable embryos, however well-intentioned,
might be viewed as a type of eugenics, or selective breeding. Given the
trajectory of genetic research, it is not inconceivable that the time may come
when parents can ‘pick and choose’ the characteristics of their child, thereby
engineering so-called ‘designer babies’. This is a very slippery slope.
Third,
the unused excess embryos are cryogenically frozen and stored for future use.
However, over time these embryos may be in jeopardy of destruction. Since our
Church teaches that each embryo is a ‘full person’, if any of these embryos are
willfully destroyed, that act is tantamount to the destruction of a person.
Fourth,
embryos stored in birth control clinics have become a source material for stem
cell research. Embryos are destroyed to retrieve the stem cells. (Stem Cell
research is further discussed below.)
Abortion
“Abortion is an act of murder for which those
involved, voluntarily and involuntarily, will answer to God”
- 1992 OCA
Synod of Bishops’ Affirmations, “On Marriage, Family, Sexuality and the
Sanctity of Life”—Abortion
Our
Church teaches that the willful and deliberate act of
aborting/discarding/destroying an embryo or fetus for the purpose of birth
control is expressly forbidden. This is why our church is against using the
so-called ‘morning after’ pill. The ‘morning after’ pill is a pharmaceutical
compound designed and sold to prevent an embryo from attaching to the uterus.
The
humanistic arguments for allowing abortions under certain circumstances, such
as in the case of rape and incest, seem at least on the surface to be somewhat
compelling and compassionate. Yet our church rejects these arguments. Why?
Because no matter what the circumstances of conception, God is always present
in the creation of a new person and that new person has just as much right to
life as a person conceived in a more ‘acceptable’ manner. Again, if this embryo
or fetus is deliberately and willfully destroyed, that act is tantamount to the
destruction of a person.
Stem Cell Research
Stem
cells are cells in our body that are used to make and replenish other cells
such as kidney cells, liver cells, brain cells, etc. These are referred to as
Adult Stem Cells. When stem cells are obtained from embryos, they are called
Embryonic Stem cells and have pluripotential properties. This means that Embryonic
Stem Cells have the capability to become any type of body cell. A tremendous
amount of research is being performed with both kinds of stem cells because of
their vast potential for treating damaged or diseased cell tissue.
Despite
the potential benefit that may come from this type of research, our Church does
not support the use of embryonic stem cells for this purpose. The rationale is
that the ‘harvesting’ of embryonic stem cells requires the destruction of the
embryo. Human embryos are considered by our Church to be full persons.
Destroying the embryo destroys the person.
While
there have been recent advances in biomedical research involving the generation
of stem cells without the destruction of an embryo, this research is in its
very early stages of development. It will be many years before any viable
therapies become available. Meanwhile, the biomedical research community still
supports the experimental use of embryonic stem cells in order to more fully
understand the biology and chemistry behind specific cell regeneration.
END OF LIFE
Debilitating Diseases, Permanent
Incapacitation and Terminal Conditions
“All efforts to heal physical and spiritual
sickness, to alleviate physical and spiritual suffering, and to prevent
physical and spiritual death are to be supported and defended.”
- 1992 OCA
Synod of Bishops’ Affirmations, “On Marriage, Family, Sexuality and the
Sanctity of Life”—Sickness, Suffering and Death
Our human
body is vulnerable to injury, disease, and the aging process. We may become
temporarily incapacitated, permanently incapacitated, or face a terminal
injury/disease. Our lives can be compromised, disrupted and changed. Dealing
with these situations can bring hardships, confusion, anger, and depression,
affecting the person who becomes ill, their family and loved ones. Yet our
Church tells us that God is with us even in times of distress, if we reach out
to Him and His grace.
Some
individuals and families handle these types of circumstances better than
others. Despite the challenges and difficulties that are brought to bear, these
situations also create unique opportunities for family, loved ones, and those
afflicted, to exercise love, compassion and understanding.
While
medical advances have expanded our choice of available treatment options over
the past 50 years, there are limitations. There are circumstances beyond the
power of medical science to heal; or which render us incapable of choosing or
exercising our options, such as in a comatose state. Consequently, it is
important that we prepare ourselves for the possibility of this type of
situation.
Any
prolonged illness or injury will always have both physical/biochemical and
spiritual dimensions. The spiritual component manifests with urgency when a
person faces permanent disability or terminal illness and must come to terms
with his/her mortality. While much has been written about dying and death,
there are no customized guidelines. Each of us will face our impending death in
our own way. However, some things can be said about this ‘final’ time of our
life on earth, if we are willing to face the fact that as our biological
existence comes to an end, we can prepare for our transition out of this world
and into the hands of God.
A myriad
of concerns may confront us when we face our mortality and impending death.
Instruction and guidance for the decisions to be made at this time are included
below.
Living Wills
A living
will, when carefully assembled and executed, addresses one’s personal,
emotional and spiritual needs, as well as one’s medical wishes. A living will,
when signed and notarized, becomes a legal document recognized by most states
of this country. Essentially, a living will designates one’s Primary Health
Care Agent and Alternates along with their specified authorities; describes the
terms of Life Support; states the kind of pain/condition management a person
wants to have; and details what the person wants their family to know
concerning their illness and/or death. Further, in order that a Living Will be
respected, it usually is necessary to appoint a person who has “durable power
of attorney for health care purposes. An excellent document entitled “Five
Wishes,” details the process of assembling a living will, and is available from
Aging with Dignity [1-888-594-7437].
A living
will benefits the person who has a debilitating or terminal illness and also
relieves the person’s family from having to make difficult decisions without
knowing the person’s wishes. The creation of a living will can be viewed as a
charitable and loving act because it fosters an environment of death with
dignity and consideration for others.
Hospice and Palliative Care
Hospice
Care, as opposed to Nursing Home care, is for persons who have entered the
end-stage of a disease. Hospice care is typically associated with end-stage
cancer but in actuality provides care for many other end-stage diseases,
including heart and liver disease, Parkinson’s disease, and many others.
The care
provided by a Hospice Center is not curative in nature but palliative. Palliative
care is the active treatment of uncomfortable symptoms, such as, pain, distress
and nausea. A proactive and integrated approach to care giving, Hospice Care
encompasses the patient and their family. While Hospice care is not curative,
it is caring and supportive.
It should
be the goal of both the family and the designated care givers to insure, as
best as they can, that the final days of a terminally ill person are spent
reasonably free of anxiety, tranquil and aware to the extent possible. Integral
to maintaining this type of condition is the administration of pain medication.
Given the wide range and sophistication of pain medication available today,
there is no reason for a person to suffer from debilitating pain.
Artificial Life Support
“Extreme caution is to be exercised in
decisions involving medical treatment, especially in the face of death. Extreme
care is always in order to find the “royal path” between providing all
necessary healing measures and merely prolonging the biological functioning of
organs when human life is no longer possible, or even present.”
- 1992 OCA
Synod of Bishops’ Affirmations, “On Marriage, Family, Sexuality and the
Sanctity of Life”—Sickness, Suffering and Death
The
development of Artificial Life Support (ALS) also made tremendous advances
during the latter part of the 20th century. These technologies, when properly
and appropriately used, provide temporary body functions enabling a person’s
body to heal itself and return to normalcy. Many are sustained by ALS assistance
while they are waiting for a suitable transplantable organ (see Organ Donation,
below). ALS is generally not regarded or proscribed as a permanent situation or
solution. Two of the more common ALS methodologies, which in recent times have
become somewhat controversial in life/death decisions, are Respiratory
Assistance (Ventilator) and Tubal Nourishment and Hydration.
ALS
methodologies, when chronically used on a terminally ill and dying patient only
serve to delay and prolong the dying process. The decision to remove all life
support and to let a loved one pass into God’s hands, while very difficult and
emotional, is necessary in order to allow the person to make his/her transition
from this world to the next. Arriving at this decision need not be, nor should
it be undertaken, alone. The decision to remove ALS should take place after
consultation with the person’s physicians and in counsel with one’s parish
priest. Most importantly, this decision should take place in communion with God
through prayer, asking for His guidance and help during this most trying and
grief-filled time.
Deep Coma, PVS (Persistent Vegetative State)
and Brain Death
A person
in a deep coma or Persistent Vegetative State (PVS) presents a number of issues
that concern our Church. The first consideration is whether the person is
technically alive or dead. The answer to that question determines what ALS
technologies should be used or not used.
Our
Church continuously acknowledges Life and its attendant Sacredness. Where there
is a clear chance of recovery, all medically available technologies should be
used to support the life of the ill or injured person. On the other hand, if
the person is terminally ill or gravely injured from which recovery is not
expected, then to use ALS technologies to simply prolong the dying process, is
basically immoral. It is important as Orthodox Christians to always keep in
mind that “Death has lost its sting.” As sad and grievous as the death of a
loved one can be, we as Orthodox Christians also know that while biological
life may end, our Life Eternal with God continues.
In deep
coma and PVS situations, the criterion for life is brain activity within the
cerebral cortex. It is activity in that region of the brain that defines the
human condition. It is the place where decisions are made, organization takes
place and speculative activities such as creative arts and philosophizing
occur. In the absence of any activity in this region, the attending
physician(s) will declare the person as ‘brain dead.” Our Church recognizes and
agrees with this conclusion. There is no rationale for the continued use of ALS
systems to maintain a biological entity when no life force is present.
Furthermore, the continued use of ALS may also make it difficult for the soul
to leave the body.
The Dying Process
“Those who suffer, and those related to the
suffering, are to be helped to find God in their affliction, and so to acquire
the divine grace and power to transform their pain into a means of purification
from evil, illumination from darkness and eternal salvation in the age to
come.”
- 1992 OCA
Synod of Bishops’ Affirmations, “On Marriage, Family, Sexuality and the
Sanctity of Life”—Sickness, Suffering and Death
Generally
speaking, there are two different but interrelated dynamics involved in the
dying process: the physical shutting down of the body and the activities taking
place on the spiritual-emotional-mental plane. No two people, if they are
conscious and aware, manage the spiritual-emotional-mental activities in the
same way.
As the
body begins to shut down, there is a corresponding change in a person’s
metabolic and circulatory processes. This will result in certain natural signs
and symptoms, such as, congestion with gurgling sounds, restlessness,
incontinence, and increasing coolness in the hands, feet and legs, to mention a
few. Further, most people, when they are told that they are dying, deal with it
in stages. Elizabeth Kubler Ross describes five stages in her book, Death and
Dying: Denial, Anger, Bargaining, Depression, and Acceptance.
Denial: “I feel fine; this can’t be happening.”
Anger: “Why me?
It’s not fair!” “NO! NO! How can you accept this?”
Bargaining: “Just let me live to see my children graduate; I’ll do anything,
can’t you stretch it out? A few more years.”
Depression: “I’m so sad, why bother with anything? I’m going to die . . .
what’s the point?”
Acceptance: “It’s going to be OK; I can’t fight it, I may as well prepare
for it.”
On the
spiritual-emotional-mental plane, the person is preparing to detach not only
from this world of ‘things’ but also from important relationships. As a
consequence, many a person has recognized certain unresolved issues and/or
unfinished business. Usually, this type of situation makes it difficult for the
person to let go. Many times, restlessness is indicative of this type of
situation. The Hospice team can help a family identify the issue and in turn
may be able to help the dying patient come to final resolution.
In the
final stage and time before death occurs, the greatest gift that we can give to
the patient is Love and the greatest gift that the dying patient can give to
their family is Love. It is worthwhile to remember that hearing remains all the
way to the end. Speak to your loved one in a soft tone of voice, identify
yourself, gently hold the person’s hands and say whatever you need to say to
help the person to let go. And, by all means shed tears without hiding them
from your loved one. Tears express our love and help us to let go.
Quality of Life, Euthanasia and Medically
Assisted Suicide
“Scientific research and experimentation are
to be undertaken with extreme caution in order not to bring greater evils and
sufferings to humankind in place of intended blessings.”
- 1992 OCA
Synod of Bishops’ Affirmations, “On Marriage, Family, Sexuality and the
Sanctity of Life”—Sickness, Suffering and Death
The term
euthanasia originally was used and understood to mean a “good death.” However,
in current times it has come to mean ‘to put an end to a person’s life by a
specific act.’ The Orthodox Church cannot and does not support such actions
whether it is executed by the patient (suicide) or by any other party
(individual or physician assisted suicide), even if the rationale is based on
the ‘relief of suffering.’
There is
the issue of removing life support systems from a terminally ill patient, which
some have described as a form of passive euthanasia. While a terminally ill
patient is generally described as someone who has been diagnosed as having only
6 months or less to live, the physical state and palliative care, including
ALS, will vary greatly during that time period from the so-called beginning to
the end. However, rather than a time window, it is better to view this
situation from the standpoint of the dying process, wherein the body has
initiated irreversible biological processes that will lead to imminent death.
Under these circumstances, our Church is not against the removal of Artificial
Life Support when it is agreed that the continuation will not lead to any
demonstrable benefit and it is consistent with the patient’s desires.
Preparation for the Funeral
Strictly
speaking, funeral preparation is not a medical bioethics issue, but it is a
related issue. It is an event arranged with thought and cares by the family and
is part of the letting-go process. However, since this is emotionally
difficult, arrangements are usually delayed until after the inevitable has
occurred and the person has died. For those who are inclined to prepare for
their funeral ahead of time and in concert with their family, there is a wealth
of information available on the internet. A very good and detailed funeral
planning document can be found on the web site: www.funeralplan.com.
Cremation
The
Orthodox tradition of burying its dead is the normative practice of our Church.
However, there has been a resurgent interest in cremation in recent decades.
While there are no canonical or dogmatic traditions prohibiting cremation, the
common practice of cremation, at least in the Roman Empire under the influence
of Christians, was abolished in the 5th century. In general, the Orthodox
Church has considered cremations in lieu of burial a dishonoring of the dead.
This is in accordance and consistent with Christ’s death, burial and subsequent
resurrection. Consequently, an Orthodox Christian lives in anticipation of
Christ’s second coming and the resurrection of our bodies. However, it is
important to realize that our resurrected body is not considered to be a
‘physical’ body but to be our ‘spiritual’ body. Thus, it follows that the lack
of a physical body, such as in the case of total destruction in a fire or
explosion, in no way affects a person’s salvation.
The most
pertinent reasons for our Church’s practice of burying its dead rests not only
on the fact of Christ’s death, burial and resurrection but also on our Church’s
teaching that there is a continuity between the ‘living’ and the ‘dead’. The
physical body demands respect because it is considered to have housed the
‘temple’ of God and as such, it too is worthy of remembrance. This is clearly
demonstrated by the bodies of the Saints whereby they have exhibited clear
signs of sanctification and holiness after their death. Further, it is our Orthodox
Church’s practice and tradition to have memorial services at the cemetery over
the body in remembrance of our departed loved ones.
There are
situations wherein certain countries (Japan) and certain states (Louisiana)
require cremation by law. In such cases the law is to be obeyed. However, the
ashes should be placed in an urn and buried in a cemetery. In all other cases,
the Orthodox practice of burial should be followed.
Organ Donation
There are
two opposing theological viewpoints within the Orthodox Church regarding the
donation of one’s body organs upon death.
First
there is the view which maintains that since we are all created in the image of
God, the harvesting of organs should be considered a form of mutilation and be
thereby prohibited by the Church.
The other
perspective is that there is no greater gift that a dying person can give than
to donate a vital organ(s) so that someone’s life may be improved and/or
prolonged. In fact, it might even be said that we are morally obligated to
provide these organs, which we will no longer need, as a gift of unconditional
brotherly or sisterly love for our neighbor.
Some
express the fear that the bodies of humans will be viewed as simply a source of
‘spare parts’. This is hardly the situation, at least in this country, whereby
Hospital and Medical Centers go to great lengths to insure informed consent;
that is to say, a person’s organs upon death are not be taken without the
expressed written consent of the patient. If an Orthodox Christian has died
without leaving written consent to remove his/her organs, they should not be
removed.
Source: https://oca.org/parish-ministry/familylife/medical-bioethics-an-orthodox-christian-perspective-for-orthodox-christians
