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Fall 2018 · Vol. 47 No. 2 · pp. 142–153 

Ministry amid Competing Values: Pastoral Care and Medical Assistance in Dying

Gloria J. Woodland

In 2016, the Government of Canada introduced legislation that allows eligible adults to request medical assistance in dying (MAiD). The social, moral, and medical ramifications of this decision are vast, but the legal reality remains: eligible adults are legally entitled to die with the help of a medical professional.

How can pastors, chaplains, and other caring members of the church community walk with people who are impacted by MAiD? How can those in ministry help individuals experience God’s presence as they sort through emotions that may range from sorrow to anger to spiritual distress?

This paper will review the realities of MAiD and seek to connect theological principles to the acute pastoral reality of those who are considering or who have chosen medical assistance in dying.

Christians must be true to themselves and their faith while truly respecting others and their choices.

THE CANADIAN REALITY

The legislation passed in June 2016 decriminalized medical assistance in dying and provided for two types of medical assistance to those wishing to end their lives: (1) the direct administering of a medication to an eligible person by a medical professional that causes their death {143} (voluntary euthanasia) and (2) the prescription or provision of medication by a medical professional for the purpose of enabling an eligible person to cause their own death by self-administration (assisted suicide). Direct administration by a medical professional is employed in most MAiD cases; self-administration is far less common. 1 Both of these practices are commonly included under the term “Medical Assistance in Dying.”

The Canadian journey towards the decriminalization of MAiD began with the decriminalization of attempted suicide in 1972. It progressed from there to a succession of private member’s bills in the House of Commons calling for the legal recognition of the right to physician-assisted death and the dismissal of criminal charges against citizens who assisted in the suicide of terminally ill persons. Further steps down the path were the Quebec National Assembly’s 2014 passage of Bill 52 (also known as the Dying with Dignity Bill); the Supreme Court of Canada’s overturning of the ban on doctor-assisted dying on January 6, 2015; and, a month later, the February 6, 2015, Carter v. Canada ruling which amended legislation to allow doctors (in specific situations) to assist patients 2 in committing suicide. These rapid developments demanded new regulatory legislation, to which the Canadian government quickly responded with Bill C-14, Legislation on Medical Assistance in Dying. The new legislation received royal assent on June 17, 2016, giving Canadians the right to receive the assistance of medical professionals in dying. 3

Even while MAiD has been decriminalized for those approaching the end of life and guidelines for eligibility and implementation have been established, there are currently ongoing court cases seeking to broaden the parameters and scope of the law for the inclusion of other population groups. The scope of MAiD could therefore be changing, and along with that, the impact of MAiD on individuals and communities will change.

MAiD DETAILS

Spiritual caregivers in the MAiD era have an obligation and responsibility to understand the context in which they will be ministering. Knowing the context of ministry will improve pastoral preparedness. And to understand the context, one must look at the practice of medical assistance in death—not to debate positions but to know what it is that Christians, as providers of spiritual care, are dealing with in seeking to minister to patients, families, staff, members of our congregations, and others impacted by MAiD.

To begin with, it is important to know the terminology and the commonly used abbreviations related to MAiD. Before current legislation, two terms were commonly used: physician-assisted suicide {144} (PAS) or physician-assisted death (PAD). Since the legislation has been passed, “Medical Assistance in Dying” is the legal term used, of which MAiD is the abbreviation. While those with Christian beliefs and values may view MAiD as the legalization of murder, it is imperative that they demonstrate both knowledge of and respect for the law by referring to the act as MAiD.

As stated above, the MAiD legislation allows a physician or nurse practitioner to directly administer medication that causes death or prescribe a drug that is self-administered to cause death. The legislation, however, requires that individuals seeking to avail themselves of their new rights first meet the following criteria:

  • The person must be eligible for health services funded by a government in Canada, be at least eighteen years of age, and capable of making decisions about their own health.

  • The person requesting assistance must have a grievous and irremediable medical condition and have made a voluntary request for MAiD and be able to give informed consent. 4

Along with these eligibility criteria, safeguards have been put in place to ensure that patients are informed, aware and able physically and mentally to voluntarily make a request for MAiD. For example, no one medical practitioner can assess the eligibility of a patient for MAiD or complete the procedure alone. An additional medical practitioner must be involved in the assessment process, and both must be satisfied that the other is independent in their judgment. Another safeguard is requiring that a patient have ten days of mental clarity between the day the request was signed and the day MAiD is to be provided. Immediately before receiving MAiD, the patient must be given an opportunity to withdraw their request or reaffirm their express consent to receive MAiD.

POPULAR SUPPORT

In an Ipsos poll commissioned by the Canadian charity, Dying with Dignity, 84 percent of the more than 2,500 Canadians who were surveyed between August 21 and August 29, 2014, agreed that “a doctor should be able to help end someone’s life if the person is a competent adult who is terminally ill, suffering unbearably and repeatedly asks for assistance to die.” 5 The opinion of that 84 percent has become law. An Ipsos poll conducted on behalf of the same charity after the passage of the MAiD legislation found that opinions had not changed. Between February 2 and February 5, 2016, a sample of 2,530 Canadians (with results weighted to reflect Canadian demographics) shows that 85 percent of Canadians endorsed the Supreme Court’s 2015 decision. {145}

At the time of writing, advance consent for MAiD—that is, consent planned and given prior to a grievous condition that could make consent impossible later on—is not allowed. However, the same Ipsos poll reports that 80 percent of Canadians support advance consent for assisted dying. Again, the majority is in favor. Included in that majority is the disturbing statistic that 76 percent of all Christians who were surveyed agree with advance consent. 6

These polls suggest that most Canadians support MAiD. Indeed, demand for MAiD in the two years after the passage of the legislation has not been insignificant. Health Canada’s “Second Interim Report on Medical Assistance in Dying in Canada,” 7 published in 2017, showed that the total number of medically assisted deaths in Canada between December 10, 2015, and June 30, 2017, was 2,149. 8

The numbers, however, only reflect the opinion of those considering the question at the time of polling, before legally requesting and receiving MAiD was an option. After numerous conversations with health care chaplains, pastors, Christian physicians, and other care providers, I have concluded that many who directly encounter the reality of MAiD find it disturbing emotionally and spiritually. The practice of MAiD elicits such a tangled web of emotions that few would call it an unequivocally positive experience.

WHAT THE BIBLE SAYS

Ministering to the suffering and needy is rooted in the biblical text, which encourages Christians to “bear one another’s burdens” (Gal 6:2a RSV, passim) and to treat “the least of these” (which includes the sick) as if they were Jesus (Matt 25:40). Jesus was, among other things, a healer of the sick, and known for his compassion for the suffering. His parable of the good Samaritan (Luke 10:30–35) gives us the very picture of compassion. As imitators of Christ, Christian caregivers thus have an ongoing missional responsibility to be present to those who for any number of reasons are suffering, not excluding those wrestling with end-of-life issues. The commentary on Article 14 of the General Conference of Mennonite Brethren Churches’ 1999 Confession of Faith expects this of pastors explicitly and implicitly of all Christians: “In cases where end-of-life decisions are being made, the pastor’s role should be readily accepted and offered graciously in support of individuals and families in need.” 9 God gives us the responsibility to listen to the cries of those nearing the end of life and respond in an appropriately caring manner.

The theological basis for resisting laws or philosophical ideas that appear to compromise the value of human life is firm. The biblical doctrine of the imago Dei teaches that since human beings are created in the image of God they have intrinsic value. As Charles Sherlock {146} explains, the sanctity of human life is derived from the wholly sacred God in whose image humans are created. If human life is so precious to God, it follows that “its existence under any conditions comes to be regarded as an absolute value.” 10

The Confession of Faith points to one other pertinent biblical affirmation, namely, that life is the gift of a sovereign God. This affirmation has immediate implications for the issue of assisted dying. In the words of the commentator on Article 14 of the Confession,

Life needs to be appreciated as a gift from God. We did not choose to be born. Nor should we choose to bring about our own death. God alone, the author of life, has absolute dominion over our lives (Deut. 32:29; 1 Sam. 1:5). Hence no human being possesses the right to dispose of life on his/her own authority. It is equally wrong to assist someone in committing suicide. 11

Christian respect for the immeasurable value and dignity of human life thus rests on belief in a sovereign and holy God in whose image we all are created and who has graced us with the gift of life. This belief also lies behind much of the Christian opposition to MAiD.

THE DILEMMA

But the legal reality remains; MAiD is now a viable option. How ought we in the church to respond compassionately to the person who cries, “I’ve had enough. Help me die”? How do we care deeply for those facing end-of-life decisions, without betraying our faith, theology, or denominational position? One answer is to respond with, “No, we don’t do that,” and then refuse all further discussion of the right to assisted dying. But that refusal constitutes—if not an abandonment of those suffering—an abandonment of pastoral responsibility and a missed ministry opportunity. 12 Moreover, the desperation that many grievously ill patients experience will, in the eyes of many Christians, make this response seem heartless.

A group of Roman Catholic chaplains recently did a role-playing exercise that had them imagine what they would do or say if asked by patients afflicted with various severe disorders to help them die. The chaplains found no preformed answers readily available. The experience left them feeling “grossly inadequate, humbled and at a loss for words.” 13 If Mennonite Brethren ministers or caregivers were to do such an exercise, I believe many of them would find themselves at a loss for words as well. I myself recall occasions in my earlier clinical experience when I was humbled to sit with acute care patients and long-term care residents and listen as they quietly shared their desire for a hastened death.

The question may be sharpened this way: How will Christian chaplains and caregivers communicate by their actions that they respect {147} the dignity and sanctity of human life all the more for embracing the doctrine of the imago Dei? How will they help those considering MAiD to treasure their lives, even when they cannot do so themselves? How do they show patients that refusal to support the hastening of death (which many people now believe shows the highest respect for the terminally ill) shows not a lack of respect for their dignity but a deeper, biblically rooted respect for them as created in God’s image?

First, spiritual caregivers 14 must themselves traverse the web of their own feelings and beliefs regarding an individual’s choice to end their life. Without a clear sense of where they stand, they cannot fully accompany those who are considering or choosing MAiD. They must be true to their faith before they can truly respect others and their choices. Moreover, understanding their own thoughts and feelings around MAiD will help bring caregivers to the place where they can accompany another and say, “I don’t have to approve your decision, but I do have to love you.” 15

Next, spiritual caregivers should be trained and prepared to help suffering individuals reflect carefully on their options and make well-informed decisions. 16 This responsibility should not be seen as merely providing information. Vicki Farley writes that spiritual caregivers should be ready to “assist the patient, family and care team in processing the decision and the implications and consequences of choosing to end one’s life. To do so involves exploring with the patient the importance of life and death. It requires both a spiritual assessment of the patient and a willingness to gently challenge the driving force behind the patient’s decision.” 17

Such a spiritual assessment will focus on a person’s sense of the meaning of their life, their suffering, their relationships, and hope or lack thereof. Caregivers will hear the patient use words like loneliness, pain, control, fear, and burden in explaining their desire to die—key words that relate to the spiritual dimension of life. These terms should be carefully considered and explored. For example, knowing what control is to the individual helps the spiritual caregiver understand what they have lost or want to control. Do they want to control the timing of death or the amount of pain they experience? Or do they want control over who does what to and for them? Loss of control is closely linked to feelings of being a burden on others. The individual’s perspective on what being a burden looks and feels like must be explored. In this way, spiritual caregivers will gain a better sense of a patient’s spirituality and, where appropriate, how it might be deepened.

Likewise, Christians who are pastorally present in suffering must use appropriate and gentle probes such as, “What would it look like for you to be out of pain?” “You seem to be in emotional distress; tell me about it.” “What do you think is the root of your suffering?” In my own clinical hospice experience, I have found that fear of the process of {148} dying and fear of the unknown permeated conversations. The spiritual caregiver will need to discuss what their patient’s greatest present fear is. Fear of mental and physical deterioration prior to death leads many to pursue a medically assisted ending of life. For others, fear of what might come after they die looms large. This is a spiritual conversation which is the responsibility of a pastoral presence or guide, who should remain open to hear the lament, fear, and sorrow, and affirming of the patient’s worth. Such pastoral conversations, conducted with integrity and sensitivity, can rekindle hope for today and for eternity.

But when a patient is so emotionally and physically depleted from their illness that MAiD has become a serious consideration, conversations will take a new direction. Health care ethicist Dr. Daniel Garros has pointed out that people explore medical assistance in dying because they are lonely, psychologically distressed, racked with unrelenting pain, and for those reasons, tired of living. Yet those who in fact obtain MAiD cite being a burden to their families and being entirely dependent on others as the main reasons for their decision. Loss of autonomy, of control of their bodily functions, and hence, loss of their dignity figure significantly in that choice. 18 In those situations, spiritual caregivers must, as Vicki Farley writes, redouble their efforts to ensure that “the care provided assists those in need to experience their own dignity and value, especially when these are obscured by the burden of illness or the anxiety of imminent death.” 19

Whenever possible, family and friends should be drawn into this conversation so that a new narrative can emerge. The experience of being a burden, for example, may be transformed into a narrative of sharing life and love for as long as possible. This is a delicate process, however, and requires special thoughtfulness. Carroll A. Wise stresses that chaplains must reach out to others at their point of need, hear their story, listen, and seek to enter the experience empathetically in order to appreciate its complexity. Only then can they participate in fashioning a new story that a patient can embrace as their own. This entering into another’s experience is what Christian caregivers must do. By opening themselves to understanding the individual’s personal experience, respecting their story and desires, they can open the door to a ministry that helps to displace a narrative of desperation with a story of courage, resilience, and undiminished dignity.

The words and actions of Christians as they help individuals explore a medically assisted death must leave space for intimate personal sharing. When such discussions are done well, believing caregivers can be sacred vessels into which suffering individuals pour their thoughts, sorrows, dreams, hopes, and questions. As sacred vessels, it is important that {149} those in ministry receive all that is shared with respect and compassion, while working to help the individual to discover that God is present and active, even in this. This soul-searching work is true spiritual care as one journeys with the individual, reminding them of God’s presence, regardless of what they ultimately decide. This is not an easy task. Referring to her own ministry, Farley says “to honor another’s choice, even when it goes against my beliefs and values, is to let go of my issues in response to God’s gift of free will.” 20 She admits, however, that “It is a heart-rending experience,” and can be profoundly discouraging if one does not “remain grounded in the holy and wholeness.” 21

CHRIST’S EXAMPLE

Christians in ministry are called to create space for intense emotions of fear and helplessness, to hear the cry of the heart, and also to demonstrate that God is present and active. All believers should take time to come to terms with their theological positions on MAiD. Legislation ensures, that in community, all Christians will sooner or later come alongside individuals who have loved ones considering MAiD, or who may themselves be contemplating it. As MAID leaves its mark on a growing number of individuals, it becomes increasingly imperative that all believers be able to respond pastorally and represent the compassion of Christ.

In the Emmaus Road story in the Gospel of Luke, Christ gives us an example of how to respond pastorally to those who were disillusioned and in turmoil (24:13–25). Jesus listened to those who were processing their loss and pondering their purpose and future. He gave “absolute unmixed attention” 22 to those he accompanied, allowing them to share their hearts and deepest thoughts. Once they had shared their narrative, Christ led them through the sacred texts and into a new awareness. In this pastoral offering of presence, they recognized that Christ was with them.

As we come alongside those who are deeply troubled and filled with life losses, we follow the example set by the Lord. Christ’s example is a reminder that spiritual care takes place in the middle of difficult situations, not apart from them. His example shows that in listening closely to the broken and suffering and by journeying with them, caregivers can show that God is present and active in their life situation. This witness is aided by a solid theological grounding. Indeed, as Karl Barth was reputed to have said, theology speaks most profoundly to others when it addresses the often frightening and upsetting circumstances of their life.

The church today is tasked with ministry in the midst of life as well as in the face of options for death. This ministry is part of the missio Dei, God’s mission to reconcile human creatures with himself and others through the grace of the Lord Jesus Christ. The missio Dei is {150} closely related to the imago Dei, as the commentary on Article 14 of the Confession of Faith makes clear: “The value of man and woman is distinct from that of the rest of creation because they are created in the image of God, a triune God who establishes a covenant relationship with them, and who sees relationships as central to being human. It is life in relationship with God and other human beings that is sacred.” 23 The role of the pastor, chaplain, or counsellor, then, is to abide with the individual, to hear their story for what it is, and to be a reminder of God as present and active there. Christians must remember that God is and that his presence is not contingent on the situation. It is in relationship, in lingering with the story, that ministry becomes a revelation of a caring and reconciling God.

SUMMARY

The struggle of ministry amid competing values centers on the tension between offering compassionate care to those seeking a solution outside the parameters of traditional Christian belief and remaining true to one’s conviction that human life, made in the image of God, is sacred. This tension between pastoral responsibility and religious conviction has become a prominent feature of end-of-life ministry. Of course, no spiritual caregiver should be asked to compromise their religious beliefs. But in a ministry that requires companioning, Christians need to become comfortable with the discomfort of theological tension, disturbing choices, and overwhelming individual, familial, and communal sorrow.

Ministry in this context challenges the church to acknowledge that “at the end of life people deserve an environment where their lives are still seen as worthwhile.” 24 That environment is not just physical; a sense of the value of a person’s life is conveyed by the presence and ministry of those who offer to travel with them on a difficult journey. At all times and in all situations, ministry must be informed by a theology that all individuals have an infinite value in the eyes of God. Words and deeds must remind those who suffer of God’s presence, especially when he appears to be entirely absent. They should communicate that “we are God’s beloved, whether or not we can personally recognize this.” 25

In representing Christ, Christians in ministry will display a nonjudgmental commitment to be present to others, as messy as things might get. Theirs is a calling to care for those who suffer that rests on a solid biblical and theological foundation. Despite the new uncertainties caused by the decriminalization of MAiD and the new fears that trouble our churches, one thing has not changed: Christians must continue to witness to Christ’s active presence to those in need. {151}

NOTES

  1. In the four months following the passing of the MAiD legislation until October 31, 2016, there were 114 cases of assisted death in Ontario alone. Only two of those cases were self-administered. (Author’s personal notes on a lecture by Dr. James Downer of the University Health Network in Toronto, November 2015.)
  2. As is fitting in a health care context, I will use the word “patient” or “individual” for those receiving pastoral or spiritual care, rather than the more awkward “patient/resident/client.”
  3. A more detailed chronology of the milestones leading to our current law:

    • 1972—Decriminalization of attempted suicide.

    • 1991—BC Right to Die Society begins lobbying.

    • 1992—BC MP Svend Robinson introduces a private member’s bill for assisted suicide.

    • 1993—The Sue Rodrigues appeal is dismissed by the Supreme Court in a 5-4 decision.

    • 1994—Sue Rodrigues dies with the assistance of an unknown doctor.

    • 1998—Quebec criminally sentences a physician for medically assisting a suicide.

    • 2005, June—MP Francine Lalonde introduces a private member’s bill, C-407, which would permit, under some circumstances, a medical practitioner to aid another person to die.

    • 2007, June—Physician from Vernon BC criminally sentenced for medically assisting the death of a ninety-three-year-old.

    • 2008, December—Quebec citizen acquitted on charges of assisting in the death of a family member.

    • 2009— MP Francine Lalonde re-introduces a private member’s bill to allow medical assistance in dying.

    • 2012, June—BC Supreme Court hears case of Gloria Taylor, ALS patient in which Justice Lynn Smith declared Canada’s law against physician-assisted suicide unconstitutional and discriminatory.

    • 2014—Winnipeg MP Steven Fletcher introduces private member’s bill for assistance in dying.

    • 2014, June—Quebec legislature passes Bill 52 allowing for medical aid in dying.

    • 2015, February 6—Supreme Court of Canada rules that the Criminal Code should be amended to allow physicians, in certain situations, to aid in dying.

    • 2016, June 17—Bill C-14, amendments to the law that allow medical assistance in dying, receives royal assent.

    • 2018—At the time of writing, MAiD is legally occurring in Canada, and while it is occurring there are court cases pressing for broader parameters for MAiD eligibility and many appeals opposing MAiD.

  4. Note that within each of the criteria for eligibility for MAiD, numerous sub-points define the criteria further. More details can be found at www.canada.ca/en/health-canada/services/medical-assistance-dying.html. {152}
  5. “Most (84%) Canadians Believe a Doctor Should be Able to Assist Someone Who is Terminally Ill and Suffering Unbearably to End their Life,” Ipsos, 8 October 2014, https://www.ipsos.com/en-ca/most-84-canadians-believe-doctor-should-be-able-assist-someone-who-terminally-ill-and-suffering.
  6. This 76 percent includes the 78 percent of Catholics who agree with advance consent for MAiD. “Eight in Ten (80%) Canadians Support Advance Consent to Physician-Assisted Dying,” Ipsos, https://www.ipsos.com/en-ca/news-polls/eight-ten-80-canadians-support-advance-consent-physician-assisted-dying, 11 February 2016. The statistical table with figures for Protestant and Catholic support can be found at https://www.ipsos.com/sites/default/files/publication/2016-02/7140-tb3.pdf, p. 8.
  7. “2nd Interim Report on Medical Assistance in Dying in Canada,” Health Canada, October 2017, https://www.canada.ca/en/health-canada/services/publications/health-system-services/medical-assistance-dying-interim-report-sep-2017.html.
  8. The total MAiD completions of 2,149 includes 167 MAiD procedures completed in Quebec prior to federal legislation receiving royal ascent on June 17, 2016. The total does not include statistics from the Yukon, Northwest Territories, and Nunavut.
  9. General Conference of Mennonite Brethren Churches, Confession of Faith: Commentary and Pastoral Application (Winnipeg, MB; Hillsboro, KS: Board of Faith and Life and Kindred Productions, 2000), Article 14 [commentary], 162. Hereinafter, Confession of Faith.
  10. Charles Sherlock, The Doctrine of Humanity (Downers Grove, IL: InterVarsity, 1996), 172.
  11. Confession of Faith, Article 14 [commentary], 157.
  12. Article 26, Health Ethics Guide, 3rd ed. (Catholic Health Alliance of Canada, 2012).
  13. Gordon Self, “Caring for Our Common Home also Means Caring for People Pleading to Leave It, Too,” Ethics Made Real column, Covenant Health Ethics Centre, June 2015, 1. Available online at https://www.covenanthealth.ca/media/91015/emrfinal19june15.pdf.
  14. For the purposes of this paper, “spiritual caregiver” includes all who will be ministering emotionally and spiritually to individuals considering MAiD and those connected with them.
  15. Vicki Farley, “The Chaplain’s Role Where Aid in Dying is Legal,” Health Progress: Journal of the Catholic Health Association of the United States, Jan–Feb 2014, 12.
  16. “The pastor’s role can include assessing a person’s underlying beliefs, fears, and spiritual condition, presenting appropriate Scripture, and providing assurance of God’s faithfulness and promises through counsel and prayer,” Confession of Faith, Article 14 [commentary], 162.
  17. Farley, “Chaplain’s Role,” 11.
  18. Gloria Woodland, personal notes, November 25, 2016, University of Alberta Health Ethics Symposium—MAiD, Edmonton, Alberta, with Dr. Daniel Garros.
  19. Farley, 11, quoting from page 14 of “Ethical and Religious Directives for {153} Catholic Health Care Services,” United States Conference of Catholic Bishops, http://www.usccb.org/issues-and-action/human-life-and-dignity/health-care/upload/Ethical-Religious-Directives-Catholic-Health-Care-Services-fifth-edition-2009.pdf.
  20. Farley, “Chaplain’s Role,” 13.
  21. Farley, 13.
  22. Phil C. Zylla, quoting from Simone Weil’s Gravity and Grace in “What Language Can I Borrow? Theopoetic Renewal in Pastoral Theology,” McMaster Journal of Theology and Ministry 9 (2007-2008): 134.
  23. Confession of Faith, Article 14 [commentary], 154.
  24. “Physician-Assisted Death / Medical Assistance in Dying,” bulletin insert distributed in 2016 by The Salvation Army Ethics Centre in collaboration with the THQ Director of Public Affairs.
  25. Denise Dombrowski Hopkins and Michael S. Koppel, Grounded in the Living Word: The Old Testament and Pastoral Care Practices (Grand Rapids, MI: Eerdmans, 2010), 205.
Gloria Woodland is Assistant Professor of Chaplaincy Studies and Spiritual Care and Director of Chaplaincy Program at MB Seminary (ACTS) in Langley, BC. She has a passion for the ministry of spiritual care.

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