Calling Evil Good
By Robert D. Orr, M.D.
Jennie was only forty-eight when she found the breast lump. The surgeon had been hopeful, but the pathology report showed the cancer was very aggressive and had already spread to the lymph nodes. Radiation and chemotherapy were completed; everyone wished for the best, hoping and waiting.
Sadly, the wait wasn’t long. In only a few months, Jennie developed back pain. The cause: spread of the breast cancer to her spine. The disease seemed to gallop through her bones, liver, and lungs. She lost weight very rapidly, became depressed, and required large doses of morphine. The medication only partially relieved her severe pain. Any movement was excruciating.
It had been several weeks since she had smiled, desired food, or even enjoyed the brief visits of her loving children. Eventually her husband, Sam, asked, “Doctor, it’s probably wrong to ask you this, but could you possibly give Jennie one large injection of morphine so that she won’t suffer anymore? She’s been in so much pain for so long. She just wants to get it over with.”
Everyone was suffering: Jennie, Sam, the children, the nurses—yes, even the doctor suffered from his inability to control the patient’s pain. All involved were ready for Jennie to die.
Understanding The Issue: Terminology
Clear thinking, or meaningful dialogue, about any issue is only possible if the meanings of the terms under debate are agreed upon in advance. In relation to euthanasia and assisted suicide, several words require definition:
Homicide is the killing of one human being by another. It is a morally neutral generic term. Homicide may be deemed justifiable (by some) in cases of self-defense, capital punishment, or war. It is accidental if done without intention; murder if done with premeditation and malice, or manslaughter if done without express or implied malice.
Suicide is the voluntary and intentional killing of oneself. In some cultures, suicide has been morally acceptable or even honorable. Many early Greek and Roman philosophers felt that suicide was an honorable death (notable exceptions were Hippocrates, Plato, and Aristotle). The Hindu practice of suttee (where a widow would throw herself upon her deceased husband’s funeral pyre), the Japanese act of hari-kari, and the Inuit practice of “going out on the ice” (where older individuals would voluntarily freeze to death when they felt they were a burden to their families) were also considered to be deaths with honor.
Our Western societal attitude condemning suicide has Judeo-Christian theological roots. In Judaism, killing oneself has traditionally been viewed as an abhorrent sin except when deemed necessary to glorify God. This narrow limitation would never justify self-interested suicide or voluntary euthanasia. This Jewish proscription against suicide has been carried over into both Christian and Islamic thought.
Although there is no specific scriptural admonition against suicide, most biblical scholars believe it is proscribed by the commandment against murder (Ex. 2 0: 13). Christian tradition has taught that suicide is wrong because it is an arrogant and improper assertion of human will that violates the intention of a sovereign God. Augustine taught that suicide was even worse than murder because there is no chance for repentance. Thomas Aquinas judged suicide to be a failure in one’s duty to oneself, to society, and to God.^^
Western secular society accepted this negative attitude toward suicide. This began in canon law, evolved into common law, and eventually into statutory law. In generations past, a person who committed suicide was “punished” by being denied a religious burial, by being buried in isolation outside the city, or even by having a stake driven through the heart. In recent decades, laws against suicide have been revoked, but most jurisdictions retain laws that forbid assistance with suicide.
Modern philosophers have developed the concept of rational suicide, usually pertaining to someone who is terminally ill and suffering. In their view it is understandable and forgivable to voluntarily and actively end one’s life to avoid further suffering. A parallel concept is altruistic suicide where a person takes his or her own life in order to avoid grave harm to others, including financial or emotional burden, or even the inconvenience of providing long-term care. The moral disapproval that once characterized Western society’s view of suicide is gradually being eroded, and many medical professionals are beginning to accept this secular philosophy.
Assisted suicide is when one individual helps another take his or her own life because the latter lacks the knowledge, courage, or physical capacity to achieve the desired end.
Physician-assisted suicide occurs when a physician has provided information, prescriptions, or a “suicide machine,” knowing that the patient’s intention is suicide.
Euthanasia means “good death” (or an easy death). Classically, it refers to mercy killing—one person, motivated by compassion, intentionally and actively killing another in order to end that person’s suffering. Most examples of mercy killing occur in the context of terminal disease (e.g., a husband gives an overdose of sleeping pills to his wife who is suffering the excruciating pain of bone cancer). Euthanasia is practiced by veterinarians, e.g., by giving a lethal injection to a severely injured or sick dog to “put it out of its misery.” This is what Sam had in mind in his request to end Jennie’s suffering: a deliberate act to bring about her rapid death. And this act of medical killing is what is meant throughout this chapter by the term euthanasia. Voluntary euthanasia means intentionally killing another person at his or her request, usually because of the latter’s suffering. Involuntary euthanasia occurs when a competent person is deliberately and actively killed, without his or her request or consent, usually because another party has decided that this person’s life is too burdensome. Nonvoluntary euthanasia occurs when it is applied to an incompetent patient.
Two other terms—active and passive euthanasia—are sometimes used, but the distinction they strive for is confusing and best avoided. Active euthanasia is defined as causing death directly by a deliberately fatal act, usually by lethal injection. But this is just another way to describe euthanasia. This redundant
Phrase’s only function is, therefore, to act as an antithesis for its likewise unnecessary semantic cousin, passive euthanasia.
Passive euthanasia is commonly used to describe situations where life-sustaining treatments are withheld or withdrawn from a terminally ill patient, with the expectation that this omission will allow the person to die naturally. Use of the term suggests that forgoing treatment that might be burdensome or serve no therapeutic purpose except to prolong a person’s dying is a form of mercy killing (euthanasia). But in such cases it is not an act or omission that causes the patient’s death but the underlying disease process. We would say that withdrawing or withholding treatment or artificial means of life support from someone who is dying is not euthanasia at all—not even passive euthanasia—but acceptable, humane, and an often appropriate part of everyday medical practice. It is not euthanasia nor is it suicide for a terminally ill but competent patient to decline life-prolonging treatment that will only extend his or her period of suffering. Thus, passive euthanasia is not a necessary or helpful term.
The ethical dilemmas raised by euthanasia are complex. As technology provides more and more ways of prolonging life and as our society moves away from a Judeo-Christian value system, including its redemptive view of suffering, people are increasingly asking their physicians to end their lives. As the value of human life and the impact of a sovereign, loving, and all-wise God diminishes in importance, other rules such as autonomy and social justice become more powerful.
The ethical principle of self-determination (autonomy), it is claimed, affirms your “right to die” with dignity. However, there is no “right to die;” there is a clearly delineated legal right to refuse treatment, even if that refusal will lead to death. But there is no legal right to be made dead.^^
Social justice (the greatest good for the greatest number) may further transform your “right to die” into a “duty to die” (if you’re exhausting family or state resources). If it is your duty to die, is it then my duty as a physician (or family member) to help you fulfill your duty to die? It may even seem immoral of me to refuse. If one calls evil good long enough, good will seem to become evil.
Even sincere Christians, committed to the biblical truth that life is sacred and of inestimable value because man is made in God’s image and He is sovereign, may find themselves requesting euthanasia when someone they love is dying and in great pain.
Sam (who loves God) requested that Jennie’s life (he also loves Jennie) be ended by immediate overdose, which would be an illegal and immoral case of “active” euthanasia. But what if the physician, in administering enough narcotic to relieve the pain, should incidentally hasten her death through depressed respiration? Is this “double-effect euthanasia” more acceptable? The principle of double effect states that if there is an action that can produce both a good effect and a bad side effect, it is morally acceptable to perform the act as long as the intention is to produce the good effect. The bad side effect is then accepted as unavoidable, but unintended. This principle has been accepted by most philosophers and theologians for hundreds of years.
If you were Jennie, what would you want? Can it be the will of a loving God that His own children suffer terribly when there is medicine that would hasten death?
When ninety-five year old Mrs. Miller was admitted to the hospital suffering from a variety of illnesses and complications, her family requested “no heroics.” The family was agreeable to providing normal sustenance (food and water) but was against providing other treatments that would only prolong her dying. Could a loving family allow Mrs. Miller to die without intensive care? On what basis would the medical team cooperate with the family’s wishes? Would withholding life-sustaining treatments be more justified if Mrs. Miller herself requested it? Is it playing God to withhold the treatment, or is it playing God to give such treatment to a patient who may be dying a natural death?
To Kill Or To Let Die?
Modern technology has developed remarkable means to prolong our living—and our dying. There is almost always something more that could be done. Someone has to decide when enough has already been done, when it is time to let the patient die. In recent years, many of these decisions have fallen to the courts, with one ruling amplifying another as the legal system has tried to grapple with these relatively new life-and-death decisions.
For example, in the case of Rudolpho Torres, the Minnesota Supreme Court ruled that the respirator sustaining his life could be disconnected because, as one writer put it, “Mr. Torres may well have wished to avoid . . . the ultimate horror not of death but the possibility of being maintained in limbo, in a sterile room, by machines controlled by strangers.”^^
Increasingly, the courts have allowed the withdrawal or withholding of life-sustaining treatments (including artificially administered nutrition and hydration) in cases broader than those where patients are terminally ill or in unrelenting pain. Although the trend is toward a broader interpretation of the right to refuse treatment, there is still a sharp division of legal, ethical, and medical opinion on the issue.
For committed Christians, what in theory may seem rather black and white can become rather gray in practice. When eighty-six year old Grandma Davis developed breast cancer, the family and doctor decided against aggressive chemotherapy. They favored less stressful hormonal treatment, knowing that while chemotherapy might prolong her life, it could also make her life miserable because of severe side effects, she might not understand the reason for the treatment, and she would be subjected to numerous injections, infusions, and blood draws. Less aggressive treatment would mean a shorter, but more peaceful life. As Grandma’s death grew near, the doctor and family decided not to feed her artificially or treat her pneumonia with antibiotics or a ventilator. She died quietly at home a few hours after receiving a dose of pain medication, and she appeared to be comfortable and pain-free at the very end.
Grandma Davis’ death was a “good death” if any death can be called good. It was certainly a better death than many others have experienced from cancer. But was it euthanasia? Were the decisions that were made good decisions? Because Grandma could not make her own decisions, the family had to make
them for her. They chose not to aggressively treat her disease, for they didn’t wish to delay the inevitable. In the end, they chose not to force-feed her, because they viewed the extension of her life a few more hours or days as inappropriate. Her physician agreed.
So Grandma Davis’ death was not a case of euthanasia. Yes, there was that injection, given just hours before her death, to ease her struggle to breathe. But in euthanasia there is rapid and intentional death, and the time of death is determined by the choice of an intruder rather than by natural causes.
Grandma Davis was not killed; she died. This is an important point, because some philosophers argue that there is no difference between active and passive euthanasia.^^ This sort of confusion muddles the real issues of medical killing. The result is that euthanasia, which is evil, can be classified as acceptable if it is allowed to be redefined by qualifying the term as passive. Such designation is incorrect. Allowing Grandma Davis to die as she did is morally acceptable. The decision to forego life-sustaining treatment is not passive euthanasia. Euthanasia as classically understood is an active process of mercy killing. Passive euthanasia is a deceptive term used by proponents of physician-assisted death to suggest that there is little difference between euthanasia and decisions to forego life-sustaining treatment. If a term like passive euthanasia is acceptable today, it becomes much easier to accept the practice of active euthanasia tomorrow.
It is critical that we make a clear distinction between physician-assisted suicide and euthanasia on the one hand, and the practice of deciding to forego life-sustaining treatment on the other. In the former, the intention is death; in the latter, the intention is to stop postponing inevitable death. In the former, there is an attitude of control, or even arrogance, in the latter, an attitude of humility. In the former, the means of death is killing; in the latter, the means of death is withholding or withdrawing treatment. In the former, the agent of death is the physician; in the latter, the agent of death is the disease. Granted, both of these practices may lead to death, but the end does not justify the means.
Arguments Pro And Con
A growing number of secular writers on the topic do not appeal to the rightness or wrongness of euthanasia but state that it should not be legalized because of the bad consequences of such a change in our society. Such bad consequences are (1) abuse: once it is considered right to end someone’s life on request, it will be much easier to presume a “request” from others (the demented, comatose, etc.); (2) error: the inherent uncertainties in medicine will cause some to die unnecessarily; (3) slippery slope: once society accepts voluntary euthanasia, it can be predicted that very quickly allowance will have to be made for those who are unable to speak for themselves; (4) distrust: if the patient knows his doctor is allowed to kill him, there will be an erosion of the traditional trust between patient and doctor—the sick will become apprehensive, uncertain of what their doctor may do to them; and (5) coercion: elderly, handicapped, and dying people may feel subtly or directly encouraged to request their legal option of euthanasia.
Regardless of all the safeguards that could be built into legislation for euthanasia, it would be impossible to prevent its expansion from the proposed voluntary request of terminally ill patients. It could easily lead to coerced voluntary euthanasia where families pressure patients into requesting euthanasia for either good or bad motives. In addition, with our legal and judicial history in this country of allowing family members to make proxy medical decisions to withdraw life-sustaining treatment from incompetent patients, it would be virtually impossible to prevent a successful court challenge in which a family member could say, “I am sure that my father would want a lethal injection at this point in his life if he were able to talk to us.” And it could easily expand to allowing requests from people who are suffering but are not terminally ill.
Derek Humphry, author of Final Exit,^^ a “self-help” volume on how to take your own life, freely admits that he believes we should be drafting legislation to permit such expanded practices, but he sees it to be politically expedient to first seek only legalization of voluntary measures.^^ It is not difficult to envision expansion within a short time to discriminatory involuntary euthanasia where incompetent patients who are a drain on the public purse would be euthanized to save money for society. Legalization of these measures would be bad public policy. These consequential arguments against euthanasia may be sufficiently convincing for some, but they cannot answer the basic question, “Is euthanasia wrong?”
Those who support euthanasia and physician-assisted death argue that competent patients who are terminally ill should have access to euthanasia or physician-assisted suicide. They claim at least three arguments for why these activities should be legalized. The first is autonomy, a person’s right to self-determination; “I am the master of my destiny.” However; if autonomy is overriding, why shouldn’t we honor requests for assisted death from anyone whether they are terminally ill or not? Their second argument is compassion. If we really care for patients who are suffering and want to help them out of their suffering, we should be willing to take these drastic steps. “We shoot horses, don’t we?” However, if compassion is over-riding, shouldn’t we meet the needs of anyone who is suffering, whether they are competent and able to request it or not? And the third argument in favor is a pragmatic one: “It works in the Netherlands.” However, recent data suggests that it is not working as envisioned; nearly one third of those euthanasized did not request this “service.”^^ The over-arching supportive reasoning is the utilitarian argument that the end justifies the means; if we have good motives and achieve good results, it doesn’t matter what we do to get there.
There are at least two strong, and I think persuasive, arguments in opposition to euthanasia and physician-assisted suicide. The first argument in opposition is that of professional virtue. Killing patients has been outside the bounds of medical care for hundreds of years. When the Hippocratic Oath first proscribed these practices, anti-euthanasia was a position held only by a minority of physicians. However, it gradually became the accepted medical professional standard—a long-standing, absolute prohibition of physicians’ taking their patients’ lives or helping them take their own lives. If the current generation of medical professionals makes this a possibility, it would change the very character of the practice of medicine. The physician would no longer be purely a healer but would be an executioner as well. This would seriously undermine the doctor-patient relationship and the trust that is so necessary to that relationship. In addition, I believe it would also detract from our current efforts in palliative care. Although we are far from perfect, we are now doing a much better job with pain control and other aspects of hospice
care than we did twenty years ago. If patients and doctors had the easy option of euthanasia, there would be less impetus to further improve end-of-life care. For these two reasons, bad consequences and professional virtue, the American Medical Association,^^ the American Geriatrics Society,^^ the British
Medical Association,^^ the Christian Medical and Dental Society,^^ many other medical professional organizations, and a large majority of physicians strongly oppose the legalization of euthanasia and/or physician-assisted suicide.
The second, and I think the strongest argument, against legalization of these two entities is the theological argument based on the sovereignty of God and the sanctity of human life.^^ God has created humankind in his own image. We are special. We are different from animals. We are not totally autonomous, but accountable to a sovereign God who has said, “Thou shall not kill” and has also shown us the compassion of the Good Samaritan.^^ We must treat each other with the reverence and respect befitting vessels containing the image of God.
By saying that human life is sacred, I don’t mean that human biological life is the supreme good. The supreme good is eternal, spiritual life with God, and that should be our primary goal. But because we are special, because our lives are sacred, because we have been placed on this earth and have been given stewardship over our lives, we must respect those lives and not snuff them out.
Another theological concept that bears on these issues but is even less popular in the secular realm, is the role of suffering in human endeavors. Many Christian writers have addressed the problem of pain and have pointed out that God may have a purpose for allowing suffering, even when that purpose is not evident.^^ He is still sovereign. But I still don’t like pain. Nobody likes pain. Nobody likes to suffer. But Scripture teaches us that there may sometimes be a role for suffering in our lives. That does not mean that medical professionals should not try their best to alleviate human suffering; that is part of the calling. But it does mean that we must humbly recognize the finiteness of our human capabilities, and our reliance upon a loving and merciful God.^^
Beyond The Pain To Meaning
People who support suicide and/or euthanasia appeal to compassion for the dying and a person’s right to final self-determination. However, most terminally ill people do not choose suicide; if they do, it is out of desperation and despair. They take their own lives because they can no longer tolerate the physical or emotional suffering they are experiencing. “I am in too much pain. I am no use to anyone. I cannot live this way.” Like Jennie, they just want to die. In their pain, suicide and euthanasia victims ignore an even more basic question: Is there any meaning or purpose to suffering? Is there really any alternative to pain and suffering? Viktor Frankl, Austrian psychiatrist imprisoned in Auschwitz for three years, says, “Suffering ceases to be suffering in some way at the moment it finds meaning.”^^ Nietzsche said, “He who has a why to live can bear almost any how.”^^
Dr. Paul Brand, noted Christian surgeon, believes there is a purpose for physical pain in our material world. He found that his leprosy patients were injuring themselves because they lacked pain sensation in their hands and feet. He tried to develop an artificial pain system for his patients, but his attempts were unsuccessful because the patients always turned off or ignored the artificial pain system. They didn’t understand their need for pain. He concluded that pain sensation is a marvel, a bioengineering masterpiece of warning and protection. Even if we don’t want it, pain is necessary.^^
But suffering is more than just physical pain. Suffering includes emotional pain (grief), social pain (loneliness), financial pain (poverty), and spiritual pain (guilt). A person may choose suicide or request euthanasia for any one or a combination of these components of “total pain.”
We do not mean to glorify suffering. On the contrary, according to the biblical worldview, painful toil (for Adam) and increased pains in childbearing (for Eve) are a part of the curse that God imposed on human beings in the material world as a result of rebellion (Gen. 3:16-17). These painful experiences were in addition to the more basic spiritual pain of a fractured relationship with the Creator.
Christians can believe and rejoice that in the kingdom, “There will be no more death or mourning or crying or pain, for the old order of things has passed away” (Rev. 21:4). But we are still inhabitants of this fallen world—the “old order of things.” If God promised us a pain-free existence on earth as a reward for following Him, people would choose to be “believers” for the wrong reason. He wants us to choose Him freely, not for what we can get out of Him. And we can’t get out of pain anyway. It happens.
But what is the purpose of a specific pain in a specific person at a specific time? Is there a purpose, or is God just impulsive? Sometimes pain is corrective. God uses it to get our attention and make us realize we are walking our own path instead of His way: “But you have planted wickedness, you have reaped evil, you have eaten the fruit of deception. Because you have depended on your own strength . . .” (Hos. 10:13). Other times, pain is meant to help us grow and develop: “And the God of all grace, who called you to his eternal glory in Christ, after you have suffered a little while, will himself restore you and make you strong, firm and steadfast” (1 Peter 5:10). God sometimes allows suffering for His glorification. The disciples asked Jesus if it was the sin of the blind man or that of his parents that was the cause of his affliction. Jesus responded, “Neither this man nor his parents sinned . . . but this happened so that the work of God might be displayed in his life” (John 9:3).
Man’s correction, man’s development, or God’s glorification. One, two, three purposes for pain; sounds nice and pat. But we know that other reasons are often hidden from us. Consider Jennie, the forty-eight-year-old woman dying of breast cancer in the prime of her life. Why? We know that the answer
Isn’t always straightforward. We are not always able to see the big picture. We are reminded in Deuteronomy 29:29, “The secret things belong to the LORD our God, but the things revealed belong to us.”
In the past, pain was accepted as a part of life; not glorified, but accepted. Today’s attitude is more frequently that all pain must be stopped and eliminated. When someone is suffering and sees no meaning or purpose, and no hope for improvement, despair is the result. This can be the path to suicide attempts or requests for euthanasia.
What should be our response to someone who pleads, “I can’t stand the suffering! Kill me or help me kill myself”? There are two valid responses, and both should be made available. One response is a hospice answer: “I can’t kill you, but I can still help you. Because I won’t kill you, I have a great moral responsibility to ease your suffering. Let me treat your pain (medically) as effectively as I can; let me hold your hand; let me help you address your emotional, financial, and spiritual needs. Let me be your friend so that when you die you will not die alone.” Hospice has demonstrated that physicians should be better educated about pain management and better equipped to treat pain effectively. More than 95 percent of cancer patients can be kept virtually pain free if they are given adequate doses of pain medication at appropriate intervals.
The other response is to try to help the person gain insight into his or her suffering, to find some meaning in the plight, to help the sufferer see that there is a sovereign, loving God who has allowed this situation for His purpose, a purpose that we may or may not be able to discern. This response involves letting God’s love shine through us. Second Corinthians 1:4 reveals that He is our example: “The God of all comfort, who comforts us in all our troubles, so that we can comfort those in any trouble with the comfort we ourselves have received from God.”
Above all, we can offer hope—the hope that pain is temporary, that glory is forever, that heaven is free of suffering and tears. And we can be with those who suffer, pray with them, and love them.
Robert D. Orr, M.D., is Director of Clinical Ethics and Associate Professor of Family Medicine at Loma Linda University, Loma Linda, California. This article is reprinted (in slightly abridged form) from the book Suicide: A Christian Response, eds. Timothy J. Demy and Gary P. Stewart (Grand Rapids: Kregel, 1998), 61-72. Used by permission.
i Robert D. Orr, “Suicide,” Decision, July 1996, 31-35.
ii Joni Eareckson Tada, “A Right to Die?” Christian Medical and Dental Society Journal 23 (1992) 4:20-24.
iii Beth Spring and Ed Larson, Euthanasia (Portland, Ore.: Multnomah Press, 1988), 137-38.
iv See James Rachels, The End of Life: Euthanasia and Morality (New York: Oxford University Press, 1986).
v Derek Humphry, Final Exit (New York: Dell, 1992).
vi Derek Humphry, “Limitations of Care; Limitations of Freedom,” public presentation in Santa Ana, Calif., October 1991.
vii See H. Jochemsen, “The Netherlands Experiment,” in Dignity and Dying: a Christian Appraisal, ed. John F. Kilner, Arlene B. Miller, and Edmund D. Pellegrino (Grand Rapids: Eerdmans, 1996), 165-79; R. L. Schwartz, “Euthanasia and Assisted Suicide in the Netherlands,” Cambridge Quarterly of Healthcare Ethics 4 (1995): 111-21; and P. J. vander Mass, J.J.M. van Delden, L. Pijnenborg, C.W.N. Looman, “Euthanasia and Other Medical Decisions Concerning the End of Life,” Lancet 338 (1991): 669-74.
viii American Medical Association, “Euthanasia, Report 12,1988,” in Reports of the Council on Ethical and Judicial Affairs (Chicago: AMA, 1989).
ix American Geriatrics Society Public Policy Committee, “Voluntary Active-Euthanasia” (Position Statement), Journal of the American Geriatrics Society, 39 vols. (1991) 8:826.
x British Medical Association, Euthanasia: Report of the Working Party on Euthanasia (London: BMA, 1988), 80.
xi Christian Medical & Dental Society, “Euthanasia,” in Opinions on Ethical/Social Issues, (Richardson, Tex.: Christian Medical & Dental Society, 1991), 17. See also Robert D. Orr, “Physician-Assisted Death,” New Issues in Medical Ethics (Bristol, Tenn.: Christian Medical & Dental Society, 1995), 181-88.
xii See for example, Robert N. Wennberg, Terminal Choices: Euthanasia, Suicide, and the Right to Die (Grand Rapids: Eerdmans,1989); Nigel M. de S. Cameron, “Theological Perspectives on Euthanasia,” Death Without Dignity (Edinburgh, Scotland: Rutherford
House Books, 1990), 37-46; and Edmund D. Pellegrino, “Euthanasia and Assisted Suicide,” in Dignity and Dying: A Christian Appraisal, 105-19.
xiii H. Wayne House, “The Good Samaritan and the Euthanasia Debate” in Suicide: A Christian Response, 399-420.
xiv C. S. Lewis, The Problem of Pain (New York: Macmillan, 1962).
xv E. Schaeffer, Affliction (Toronto: Welch,1973); Philip Yancey, Where Is God When It Hurts? (Colorado Springs: NavPress,1989); David B. Biebel, If God Is So Good, Why Do I Hurt So Bad? (Colorado Springs: NavPress, ] 989); G. E. Pence, “Do Not Go So Slowly into That Dark Night: Mercy-Killing in Holland,” American Journal of Medicine 84 (1988) 1:139-41.
xvi Viktor Frankl, Man’s Search for Meaning (New York: Pocket Books,1963), 179.
xvii Ibid., 164.
xviii See Philip Yancey’s, Where Is God When It Hurts? (Grand Rapids: Zondervan, 1992).
 Robert D. Orr, “Suicide,” Decision, July 1996, 31-35.
 Joni Eareckson Tada, “A Right to Die?” Christian Medical and Dental Society Journal 23 (1992) 4:20-24.
 Beth Spring and Ed Larson, Euthanasia (Portland, Ore.: Multnomah Press, 1988), 137-38.
 See James Rachels, The End of Life: Euthanasia and Morality (New York: Oxford
University Press, 1986).
 Derek Humphry, Final Exit (New York: Dell, 1992).
 Derek Humphry, “Limitations of Care; Limitations of Freedom,” public presentation in Santa Ana, Calif., October 1991.
 See H. Jochemsen, “The Netherlands Experiment,” in Dignity and Dying: a Christian Appraisal, ed. John F. Kilner, Arlene B. Miller, and Edmund D. Pellegrino (Grand Rapids: Eerdmans, 1996), 165-79; R. L. Schwartz, “Euthanasia and Assisted Suicide in the Netherlands,” Cambridge Quarterly of Healthcare Ethics 4 (1995): 111-21; and P. J. van der Mass, J.J.M. van Delden, L. Pijnenborg, C.W.N. Looman,
“Euthanasia and Other Medical Decisions Concerning the End of Life,” Lancet 338 (1991): 669-74.
 American Medical Association, “Euthanasia, Report 12,1988,” in Reports of the Council on Ethical and Judicial Affairs (Chicago: AMA, 1989).
 American Geriatrics Society Public Policy Committee, “Voluntary Active-Euthanasia” (Position Statement), Journal of the American Geriatrics Society, 39 vols. (1991) 8:826.
 British Medical Association, Euthanasia: Report of the Working Party on Euthanasia (London: BMA, 1988), 80.
 Christian Medical & Dental Society, “Euthanasia,” in Opinions on Ethical/Social Issues, (Richardson, Tex.: Christian Medical & Dental Society, 1991), 17. See also Robert D. Orr, “Physician-Assisted Death,” New Issues in Medical Ethics (Bristol, Tenn.: Christian Medical & Dental Society, 1995), 181-88.
 See for example, Robert N. Wennberg, Terminal Choices: Euthanasia, Suicide, and the Right to Die (Grand Rapids: Eerdmans,1989); Nigel M. de S. Cameron, “Theological Perspectives on Euthanasia,” Death Without Dignity (Edinburgh, Scotland: Rutherford House Books, 1990), 37-46; and Edmund D. Pellegrino, “Euthanasia and Assisted Suicide,” in Dignity and Dying: A Christian Appraisal, 105-19.
 H. Wayne House, “The Good Samaritan and the Euthanasia Debate” in Suicide: A Christian Response, 399-420.
 C. S. Lewis, The Problem of Pain (New York: Macmillan, 1962).
 E. Schaeffer, Affliction (Toronto: Welch,1973); Philip Yancey, Where Is God When It Hurts? (Colorado Springs: NavPress,1989); David B. Biebel, If God Is So Good, Why Do I Hurt So Bad? (Colorado Springs: NavPress, ] 989); G. E. Pence, “Do Not Go So Slowly into That Dark Night: Mercy-Killing in Holland,” American Journal of Medicine 84 (1988) 1:139-41.
 Viktor Frankl, Man’s Search for Meaning (New York: Pocket Books,1963), 179.
 Ibid., 164.
 See Philip Yancey’s, Where Is God When It Hurts? (Grand Rapids: Zondervan, 1992).