Free to Die: A Lutheran-Relational Approach to Medical Assistance in Dying

In 2016, Canada legalized Bill C-14, which removed from the Criminal Code medical assistance in dying (MAID) under certain circumstances. In essence, the Bill legalized what is commonly described as euthanasia, under the provisions that the patient has a terminal medical diagnosis, anticipates extreme suffering, is at least 18 years old and still maintains their own medical power of attorney, has received the same diagnosis from two separate doctors, and requests such a procedure without duress. The bill exempts doctors and nurses from culpability in murder, along with those aiding the medical staff. The bill replaces sections of the Criminal Code that criminalize death by suicide. In this article, I first review the theological and historical interpretation of suicide within the Christian church. I then offer a specifically Lutheran feminist framework of our baptism into death, Luther’s explanation of the First Commandment, and Christian freedom to affirm Christians’ faithful decisions in seeking medical assistance in dying.


Introduction
In 2016, Canada legalized Bill C-14 1 , which removed from the Criminal Code medical assistance in dying (MAID) under certain circumstances. In essence, the Bill legalized what is commonly described as euthanasia, under the provisions that the patient has a terminal medical diagnosis, anticipates extreme suffering, is at least 18 years old and still maintains their own medical power of attorney, has received the same diagnosis from two separate doctors, and requests such a procedure without duress. The bill exempts doctors and nurses from culpability in murder, along with those aiding the medical staff. The bill replaces sections of the Criminal Code that criminalize death by suicide.
Since then, various Canadian denominations have struggled with appropriate pastoral and theological responses to this change in Canada's laws. The Canadian Conference of Catholic Bishops opposes the legislation, while the Anglican Church of Canada, the United Church of Canada, and the Evangelical Lutheran Church of Canada (ELCIC 2018) have all produced pastoral responses to the issue that accommodate but do not necessarily recommend their members taking advantage of the legislation. From 2015 to 2017, the ELCIC engaged in a congregational study process to examine the theological, faith, and cultural perspectives on MAID, which resulted in a resolution coming to the floor of the 2018 National Convention. "The Call to Faithfully Journey with those who are Dying: An ELCIC Resolution" affirmed the right to life, the right to assistance in dying as a faithful act, the right to quality palliative care, and the right to dignity in death. This resolution was passed at the 2019 National Convention by the assembled body. This article is an adaptation of material the author was invited to submit to the ELCIC's Task Force on Decisions at the End of Life. It was written after legislation by the Canadian government and served as foundational material for the Study Guide and the resulting resolution. The intention was not to challenge the already-legalized bill, but to offer an alternative theological perspective to previous denominational statements, and was one of many perspectives solicited. (LCA 1978(LCA , 1982ELCIC 1997) This article specifically examines the role of suffering in decisions to end life, as this is the core argument of the Canadian legislation. While there are undoubtedly other issues at stake, including those of medical professionals to refuse to act against their conscience, decriminalization of suicide, and the role of religion in shaping proposed legislation, this article does not address those. As such, it first reviews the theological and historical interpretations of suicide that have formed the foundations of understanding in the Christian church. It then offers a specifically Lutheran feminist framework of our baptism into death, Luther's explanation of the First Commandment, and his understanding of Christian freedom to affirm Christians' faithful decisions in seeking medical assistance in dying that emphasizes the compassionate relationality of God with us as the primary lens through which these are interpreted.

Wanting to Die
When I was fourteen, I wanted to die. A sentence in my diary from that time reads, "I want to die. I feel so alone. If it wasn't a sin and I would go to hell, I would kill myself." While those may seem to be the melodramatic words of a teenager, they came from the heart of someone deeply depressed. Remembering that moment in my life, I know that they were true. Had I not believed at that time that suicide was a sin, I would have found a way to end my life. The belief that suicide condemned one to hell saved my life. When we read the statistic that one in five Canadian teenagers has contemplated suicide, a number much higher in our indigenous population, we can be grateful for whatever vestiges of Christian thought remain in our culture that are preventing them from taking such action.
Twenty-five years later, however, as a pastor I regularly sit in the presence of those much older and wiser than I, who had already lived through six or seven or even eight decades by the time I had made my desperate pronouncement. And they, too, express a wish to die. At the end of long and fruitful lives, their bodies have become tortuous prisons, burdens that hold them back from rejoicing in the lives they have lived. They are often the last member of their generation and their circle of friends. They speak of heaven as a family reunion, wondering how long until they can join the party.
Within the church community, we have brothers and sisters who, for various reasons, want to die. We are naturally filled with sorrow that this is how they experience life, and we want to alleviate their pain. But what may bring joy in one situation may increase pain in another, and vice versa. As a church, we are called to hold diverse perspectives together, just as God holds together the diversity of humankind in one hand. The thoughts below reflect my concern for those who have already experienced much of life, while remembering the pain of my younger self and the gratefulness that, misguided or not, I carried on.

The Role of Suffering in the Christian Life
The current legislation emphasizes the role of suffering in the decision to take advantage of MAID. Christians who suffer, physically, mentally, or spiritually, have been encouraged to turn to Christ and to take heart from the ways in which his own suffering led him to the cross and eventually to resurrection and new life for the world. We are presented with an understanding of suffering that gives meaning to what seems an otherwise meaningless situation. Suffering is interpreted as God's will, even as a sign of God's justice--either punitive for a sin we committed in the past, or restorative to bring us closer to Christ and to others who suffer. We consider suffering a "trial," and ask in the Lord's Prayer to be saved from that time, much as Christ asked that the cup would be passed from him in Gethsemane, insofar as it is God's will.
For those Christians who find strength in such understanding, it is imperative that we not unmoor their faith by denying that God works in this way.
However, there are a significant number of Christians for whom suffering is not a sign of God's working with the world. These Christians believe, perhaps implicitly, that God does not work so closely within the mechanics of the world as to cause cancer, or car accidents, or dementia, or strokes. They do not attribute the cause of the suffering to God's plan for them--it is simply one of the "things that happen" in the world. To tell them that their suffering is God's will is actually to increase their spiritual suffering, as they then wonder what they have done and begin to question the graciousness of God. They turn from God to themselves, in order to determine their misstep.
When we examine suffering within the context of MAID, the issue is not whether or not suffering is an integral part of Christian witness, but whether enduring it is voluntary. In the last century, theologians have begun to shift our image of God from a patriarchal figure who knows what's best for us and corrects us through sheer force of (God's) will to that of a more relational figure who grants us the gifts and agency to choose our own path in life, learn from our mistakes, and grow. As in any healthy parent-child relationship, God grants God's children ever-increasing freedoms so that we may mature into autonomous and compassionate adults. Freedom to make decisions--agency--becomes an important factor in God's relationship with us, and our relationship with one another. In this understanding, suffering is therefore meaningful only when it is voluntarily endured. Those who choose to live with it, for whatever reason, find meaning in that choice, but forcing another to experience or accept suffering--removing their agency--renders it meaningless. Mary Streufert uses the example of a mother to illustrate this point: a woman who chooses to become pregnant voluntarily endures the suffering of childbirth and the painful loss of autonomy during pregnancy and the first period of raising an infant, but since this is voluntarily chosen, finds meaning in her suffering as it leads to new life for others. (Streufert 2006). The key is that the suffering is voluntarily endured, and that we maintain the agency that God has granted us. This is not to say that we can only enter into suffering voluntarily. It is most often the case that we unwillingly and unexpectedly find ourselves in the midst of suffering. It is at that point, and many more points that follow, that we question whether or not we choose to continue on in that state. Some Christians may do so without doubts, solidly rooted in a faith that helps them to see this carrying their cross and following Jesus. They choose to interpret their lives in this way. Others find themselves vacillating between finding meaning in their suffering and feeling abandoned by God. A third group rejects God's presence in their suffering altogether, believing that God does not desire for us to experience such things. With each group, we do well to honour the words of Stanley Hauerwas, who cautions that, "it is one thing for us to make our own suffering part of our life in service to God, it is quite another to make another's suffering part of his or her service to God." (Hauerwas 1990).
We do not encourage the belief that life is a test of faith, to be endured so that the one suffering may be welcomed into heaven. We are open to the possibility that there may "be a point at which one's physical being can be so racked by disease that embodiment, in effect, comes to represent an evil". (Kaldjian 1999. Kaldjian actually takes the opposite position--that there is no point at which embodiment can be evil.) We are not called to lift up those whose life is painfully burdensome, for instance our senior seniors, as the new martyrs of our church, enduring the suffering of bodily life so that the faith of the community may be preserved. For Lutherans, redemption and salvation come solely from Christ's suffering and death on the cross--which he himself freely chose, exercising his own agency in that matter--and not from our own.

Biblical, Theological, and Pastoral Considerations
As Lutherans, we always begin our deliberations with the Bible. Yet our Bible is ambiguous when it comes to voluntarily-chosen death, neither outright condemning it nor encouraging it. No moral judgement is made of those who chose death, either with their own hand or through another's. In Judges 9:54, Abimelech directs his servant to kill him after being mortally wounded by a woman, so that he might not be shamed by death at the hands of a women. In 9:56-57, his death is interpreted as pre-ordained. The death of Samson in Judges 16:25-31 is understood as being assisted by God, because he did not have his own strength to push down the pillars, and he is honoured after his death. Saul requests a mercy-killing from an attendant in 1 Samuel 31:3-40, and his death is understood variously as pre-ordained, as a punishment for the times he tried to kill David, and he, too, is honoured after his death, as is the slave who demonstrated his loyalty to Saul. The rabbinic commentary, Genesis Rabbah, endorses his suicide. (34:13) 2 Samuel 17:23 records the death of Ahithophel, a wise man who set his affairs in order before killing himself in protest against the king, and notes that he was buried in his ancestral tomb.
In Paul's epistles, we find additional ambiguity. Paul describes his longing for death, and his desire to leave this human body to be united with Christ (Philippians 1:21-26, 2 Cor 5:1-8). Indeed, the fervent nature of his writings has led scholars to debate whether he did actually intend suicide (Cray 2003). It is important to note, however, that there is no record of Paul actually carrying out his wish to die, yet neither does he see death as something to be deferred.
The predominant Christian understanding condemning voluntarily-chosen death comes from Augustine, the first Christian to address the issue in a straightforward manner. At the beginning of the fourth century, a series of Roman Emperors ordered the capture, torture, and execution of all Christians who would not recant their faith and turn to worshipping Roman gods. As a result, many Christians chose to die rather than abandon their Christian faith. Others, on the other hand, chose to hand over their Scriptures as a substitute, and were thus spared death. When the persecutions came to an end, the Christians who came afterward accused those who had survived the persecutions as traitors, and argued that they should have chosen to die rather than submit. The disagreement between these two groups of Christians caused controversy within the Church at large, and disrupted both the religious and political stability of the Empire.
Augustine, who was the bishop of Hippo, argued that those who handed over Scriptures to avoid death were not faithless Christians. To counter the vehement nature of the arguments by those who advocated that Christians should choose death, he emphasized that voluntary death (suicide or martyrdom) was equal to murder. "The commandment is, 'Thou shalt not kill man;' therefore neither another nor yourself, for he who kills himself still kills nothing else than man." (Augustine 2014, chp. 20) Augustine reviewed several cases of Christian women who had chosen to kill themselves rather than be raped, and concluded that their fear of bodily pain or public shame was evidence of weak thought: "Is it not rather proof of a feeble mind, to be unable to bear either the pains of bodily servitude or the foolish opinion of the vulgar?" (Augustine 2014, chp. 22) His aim was to reduce the number of Christian suicides during a period when there was no longer any external pressure for them to die.
Nevertheless, Augustine made one singular allowance for suicide, reflecting on the case of Samson. He argued that Samson was inspired by the Holy Spirit, who had given him "secret instructions" to lean against the pillars of the hall of the Philistines and cause the roof to cave in, killing himself and those in the hall. (Augustine 2014, chp. 21) Augustine thus allowed for the possibility that certain individuals might be directed by God to kill themselves as part of some divine mission, in which case their death was no longer a violation of the fourth commandment. While he could not judge whose death was from God, he did argue that these cases were very few and far between.
After Augustine's argument, there were no further theological developments in voluntarily-chosen death. Thomas Aquinas, who is often cited as the other church authority on suicide, followed in Augustine's footsteps, arguing that killing oneself was a violation of the commandment not to kill. (Aquinas 2006, Part II of Part II, Question 65, "Of Murder") Aquinas presented his objections in three arguments: (1) Killing oneself is "contrary to natural law," since it is our nature to care for ourselves: "Suicide is a sin in relation to oneself." (2) Killing oneself "injures the community," since we belong to the community into which we are born and removing a part of that community damages the whole. And (3) the person who kills oneself "sins against God," who alone is given the power over life and death. Aquinas reasoned that since our life is not ours but God's, we are "usurping" God's decision and action in this matter, which is a rebellion against God. He acknowledged that we are free to decide how to live the life we are given, but "the passage from this life to another and happier one is subject not to man's free-will but to the power of God." (Aquinas 2006) When considering "centuries of theological practice," it is important to remember that the vast majority of Christians in the ELCIC have grown up with the values, culture, and philosophical underpinning of Western thought. We are influenced by Augustinian thought in a subconscious way that requires much unpacking to articulate and understand. Aquinas' argument that the choice for life or death is not ours to make continues to resonate strongly with many people. Yet it is no longer the case that all Lutherans in Canada are from Western countries. As we welcome more Lutherans with other cultural backgrounds, we must be mindful that they will be influenced by different schools of thought, particularly when it comes to suicide. In Japan, for instance, suicide is not understood as shamefully as we do, and certainly not as a sin or rejection of God. In China, suicide is influenced by Confucian thought, which does not outright condemn it as Augustine did. We must be careful not to mistake our cultural and philosophical values for theological truths, nor to impose them on those who have come to belong to our church community from different starting points.
We are living in a context that neither Augustine nor Aquinas could have imagined. Augustine was addressing Christians who were encouraged to choose death as a demonstration of their faith, and argued that given the choice between apostasy and death, apostasy was preferable. Aquinas understood bodies as the property of God. The current context of medical assistance in dying involves opposite concerns: a life of suffering (rather than death), and the freedom from life rather than the freedom from death. While we share with our Christian forerunners the same concern that we should all experience the goodness of God's gift of life, and the desire to fulfill God's wishes for us, our understandings of what constitutes that goodness and of what those wishes might be have changed. In circumstances where medical assistance in dying is being considered, Christians are not having their faith tested by the threat of death, but rather by the threat of life. Christians are not facing the question of what kind of death does God ask us to endure, but what kind of life. Does God ask us to endure any kind of life at all?

A New Understanding
Keeping in mind the above reflections on Christian suffering, particularly that no one can impose suffering on another, particularly for their spiritual good, there are two theological avenues to consider--one rooted in Luther's interpretations of what it is to be a faithful Christian, and what human freedom entails, and the other turning to much newer understandings of God.

We Are to Fear, Love, and Trust God above All Things
Luther begins his Small Catechism explanations of each of the Ten Commandments with the line, "We are to fear and love God." For each commandment, he directs the reader back to the First Commandment, "You are to have no other gods," and to his explanation that "We are to fear, love, and trust God above all things." Lutherans, then, in all our considerations, must ask ourselves: what do we fear, what do we love, and what do we trust? Which fears, loves, and securities are directing our decisions? Do we make our decision because we are moving towards something, or because we are running away from something? Faithful disciples will seek, in all their decisions, to move towards God and away from fear of loss, or fear of death, or fear of dignity.
Yet in questions of whether requesting medical assistance in dying is appropriate or justifiable in given situation, the decision to fear, love, and trust only God does not take one singular and universal form. One patient may certainly be motivated by fear of suffering, fear of shame as bodily and cognitive functions break down, fear of facing an unknown future. In this case, fear becomes their God, and choosing to die demonstrates an (understandably human) inability to place their full trust in God. On the other hand, a different patient may be motivated by loving and trusting God, by the security that God is indeed committed to granting us an Easter life after death, and by relying on the promises of baptism that we will live with Christ. Trusting in God's covenantal love becomes the primary lens for following the First Commandment, rather than simply imitating Christ's suffering unto death (Trelstad 2010). Luther himself, in his sermon, On Preparing to Die, introduced death as that time in which we give a farewell to our life on this earth in order to joyfully enter our life with God. For this latter patient, neither death nor life are the objects of fear. Instead, love and trust directs their actions, and God remains truly and fully God. In some cases, choosing physician-assisted death is a betrayal of God, as Augustine and Aquinas might argue, but in other cases, it is a form of self-care that results in the final, ultimate act of surrender into God's complete care. It can be seen as the last act of self-determination in which the goal is to turn everything over to God. In both situations, the outcome is death, but the motivation is very different.
The same dichotomy is true for choosing not to pursue physician-assisted death. One patient may pursue ongoing medical treatment (aggressive or passive) out of fear of death, while another patient may pursue it trusting that God may yet work something new in this lifetime. The outcome in both situations is life (as a deferral of death), but the motivations are different. The questions for the faithful Christian debating continued life or accelerated death are: does one's choice come from a place of fear or a place of trust? Is it move away from the pain of this life or a move toward the peace of life with God?
As Christians, we determine how to live lives that demonstrate our fear, love, and trust of God by re-enacting our baptism. We die to live and live to die. As Marty Stortz writes, "Baptism is the sacrament that welcomes people into this world as children of God. It incorporates them into the body of Christ. Yet, that incorporation is finally complete only in death. Baptism ushers people out of this world. . . . Death in the Lord is final inclusion into the body of Christ" (Stortz 1999). The embodiment of a life of baptismal faith looks different for every body. God allows us to choose how we shall live a life that demonstrates that death does not have the final victory, and this leads to the richness and diversity of individual lives in the larger church community. When we die, we are incorporated into the larger body of saints that have gone before us, each of whom walked their own baptismal path. Both one's life and one's death witness one's baptismal faith to the larger community, and contributes to the building of what will become tradition for later generations.
To fulfill the First Commandment, in baptism we are blessed with the power of the Holy Spirit, who empowers us to be faithful, to seek God's will, and to live without fear of death. We trust, then, that each baptized Christian makes their decisions regarding physician-assisted death with the desire to be faithful. As a church, as spiritual leaders, as pastoral care-givers, and as Christians, we remind one another that God is to be trusted to love us regardless of our choices. We exhort one another with the proclamation that the new life of Christ awaits all of us when we die, and that "neither death nor life," nor manner of death nor manner of life, "will be able to separate us from the love of God in Christ Jesus our Lord." (NRSV Romans 8:38-39) We leave one another free to experience--live in and live out--the graciousness of that love howsoever they choose.

Freed to Live, Freed to Die?
The idea that God gives us freedom leads to the next option for considering physician-assisted death. While Aquinas argued that we are free to live, but not free to die, it is time to reconsider the latter half of that argument, looking to a theology that argues for a relationally-based understanding of God.
As mentioned above, Aquinas' argument that life is a gift from God, and that the power to begin or end life rests solely with the one who Created us, is pervasive amongst Christians today. In my experience with senior seniors (ranging in age from 90-104), the majority of them express the wish to be done with this life, pray nightly not to wake up the next morning, and yet conclude with, "But it's not my decision to make." Christians remain concerned that if the moment of our death rests solely in God's hands, then determining that moment for ourselves is a repudiation of God's sovereignty in our lives.
Our fear of death often forecloses certain avenues of exploration, but as Christians we are not to fear death, and thus can question and challenge the presuppositions we hold. Therefore, we may ask, what if the original premise is not true? What if God does give us the freedom to decide the moment and method of our own death? Bracketing the discomfort and anxiety that raising such questions evokes, we can explore more fully God's relationship with us.
Relationally-based theology explores the idea that God exists in relationship with us, and grants us the freedom to be co-Creators of our world and life, so that we might, through decisions, successes, and mistakes, grow to be the mature individuals God has created us to be. The relational theology of Thomas Oord argues that in this freedom, God relates to us through kenosis (self-emptying) and mutuality (Oord 2015). In contrast to the traditional characteristics of omnipotence, immutability, and impassibility, God empties God's self of universal and absolute power in order to share power with us. Because God is in a mutually-formative relationship with us, God thus sacrifices God's impassibility so that God might suffer when we suffer, rejoice when we rejoice, and thus truly share the embodied, enfleshed nature of our lives. In essence, God grants us full agency over our lives, so that we might become fully realized humans, as God has created us to be.
No relational theologian has addressed the issue of suicide or physician-assisted-death, but there is room within the understanding of relational theology to do so. In giving us full agency in our lives, God gives us the privileges and responsibilities to make decisions about both our lives and our deaths. In this understanding, then, the choice to die is not a repudiation of God, or a sin as Augustine and Aquinas understand it, but rather a choice that God has already granted us to make. Indeed, many of the choices we make during our lives are choices between life and death in a less physical way--choosing one career means the death of another, choosing one relationship to focus on can mean the death of another, choosing to move to a new city means the death of participation in the first neighbourhood. While the finality of choosing physical death seems to surpass the deaths of our other choices in this world, it is no more "final" to our Easter God than any other form of death. While Aquinas rightly identifies that only God has the power of life and death, in a relational-theology understanding, God willingly shares that power with us. In giving us the freedom to live, God also gives us the freedom to die. When our choices are made from a place of fear, love, and trust of only God, God frees and empowers us to move towards God in whatsoever manner we choose.

Conclusions
God created our bodies to be a medium of joy for us. They are "very good." (Genesis 1:31) The Word of God became flesh, reaffirming the goodness of material existence. When we no longer experience our bodies as sites of joy and goodness, but only as sites of suffering, we can affirm that our lives are not as God intended them.
The choice to remain in our bodies and find meaning in our suffering as we continue to live or to relinquish our claim to them and die, is one that no one can make for us, as much as we might wish it were otherwise. It is true that in a perfect world, we would neither need nor desire physician-assisted death. Since we still wait for the fullness of the kingdom of God on earth, we continue our struggle to cope with the imperfections of this one. These struggles are never encountered in isolation, although it may certainly seem that way, but are shared by the community into which we are baptized. The decisions we make have consequences for those around us. This applies equally to those who choose medical assistance in dying as to those who would discourage others from making that choice. If we consider our lives to be a gift from God, it may be a gift to the entire community rather than solely to ourselves, as Aquinas directs us to consider. We, as individuals, are called to be stewards of our lives, on behalf of the larger community and on behalf of God, but ultimately we alone are responsible for our own individual lives. We live in a country that has legislated that we have the freedom and right to request medical assistance in dying. As a church, our place is not to prohibit that now legal right in its availability to all citizens, nor to dictate for other Christians what their faith-filled decision must be. Our place is to guide one another always to move towards God in faith, love, and trust, and to humbly walk alongside one another in that journey.
As Lutherans, we do not counsel one another to choose death. Neither do we coerce or elicit through threats of damnation the choice for life. We do not seek to be the judge of another's spiritual or rational capacities. Only God is capable of the first, and only highly trained medical professionals are capable of the second. Rather, we treat the one making a decision regarding physician-assisted-death with both compassion and respect. The desire to die is more complicated than either Augustine or Aquinas suggest--it is not a sign of a "feeble mind" or of ceasing to care for one's self. Whether, after prayerful and thoughtful consideration and conversation with loved ones, one chooses to continue with physical life or to end it, in both cases, we offer our support to those who make the choice for themselves, who act in the freedom God has given them, and who do so moving forward in trust to claim for themselves the new life God has granted us in baptism.