Medical Bioethics: An Orthodox Christian Perspective for Orthodox Christians

By Protodeacon Basil Andruchow

Introduction

The understanding and discussion of contemporary medical bioethical issues is, for Orthodox Christians, predicated on the tenets of the Orthodox Church. These tenets help us to frame the right questions for consideration from the very beginning. The first of these questions asks why humankind exists on earth. The following statements reflect the teachings of the Orthodox Church in response:

• God created the world and all that is within it.
• God created mankind, both male and female, in his image and likeness. Mankind is considered sacred and is eternally precious in God’s sight.
• We are called by God/Jesus Christ to live our lives in a continuing state of becoming like God.
• We strive to be in union with God while on this Earth with the expectation, hope and belief that we will be with Him in life everlasting.

Within this context, the concepts, topics, and issues of contemporary medical bioethics must be carefully considered. What follows is a framework for understanding the Orthodox Christian perspective as it relates to medical practices and individual decision-making.

In 1992, the Holy Synod of Bishops of the Orthodox Church in America issued its affirmations “On Marriage, Sexuality and the Sanctity of Life”, which can be obtained from the OCA web site, www.oca.org. Where applicable, a particular relevant affirmation may be included in a particular topic section.

This synopsis of some of the more important medical bioethical issues facing us today as Orthodox Christians is not intended to be a complete presentation of all the issues and topics nor should it be considered an official document. Rather, it is intended to spark thought and discussion with regard to medical bioethical considerations and decision-making.

BEGINNING OF LIFE

Conception

“God wills that men and women marry, becoming husbands and wives. He commands them to increase and multiply in the procreation of children, being joined into “one flesh” by His divine grace and love. He wills that human beings live within families (Genesis 1:27; 2:21-24; Orthodox Marriage Service).”
1992 OCA Synod of Bishops’ Affirmations, “On Marriage, Family, Sexuality and the Sanctity of Life”—The Mystery of Marriage

The Orthodox Church teaches that ‘full personhood’ is present at the time of conception, when the male sperm and the female ovum nucleus merge to form the single, 46 chromosome, totipotential cell called the zygote. The zygote is a biologically unique and complete individual. Following mitosis, or cell division, the developing embryo moves down the fallopian tubes of the woman. The fully developed embryo then attaches to the uterine wall, continues fetal development and is subsequently born into the world. The understanding of and belief in the ‘full personhood’ of the zygote, and thereby the embryo, dictates our Church’s position with regard to abortion and certain aspects of stem cell research.

Conception Control

“Married couples may express their love in sexual union without always intending the conception of a child, but only those means of controlling conception within marriage are acceptable which do not harm a fetus already conceived.”
1992 OCA Synod of Bishops’ Affirmations, “On Marriage, Family, Sexuality and the Sanctity of Life”—The Procreation of Children

The Orthodox Church does not support the general use of contraceptives for conception control. The understanding of our Church’s position with regard to contraceptives is based on the fact that a husband and wife form the basic foundation of the family unit. Sexuality within a Christian marriage is a blessing; the couple in love is expected to bring forth children who are the fruits of the union of “one flesh.” A couple must be willing to accept the possibility of pregnancy from this act of love.

On the other hand, our Church understands that there may be some very compelling reasons for the use of birth control measures. An example is the case of a woman whose health and well-being would be severely jeopardized if she had a child. Matters of this type have a very large pastoral component to them and should be discussed with the couple’s parish priest.

In-Vitro Fertilization

“Married couples may use medical means to enhance conception of their common children, but the use of semen or ova other than that of the married couple who both take responsibility for their offspring is forbidden.”
1992 OCA Synod of Bishops’ Affirmations, “On Marriage, Family, Sexuality and the Sanctity of Life”—The Procreation of Children

An infertile couple may agonize over the fact that they are childless. In the past, this was a fait-accompli. With the rapid development of medical fertility science in the latter part of the 20^th century and continuing to this day, techniques have become available to assist childless couples in their efforts to bear children, particularly through the method of in-vitro fertilization. Essentially this method involves the fertilization of the wife’s ovum/egg with the husband’s sperm in an environmentally controlled Petri dish. The resulting embryos are allowed to develop to the stage just before uterine implantation. Three to five of the most viable embryos are selected and placed in the wife’s uterus with the hope of implantation and subsequent birth of a child.

While our Church recognizes the potential benefits that may be derived by a childless couple using the services of a Fertility Clinic, it should be noted that this type of service is expensive and may not always succeed. Again, this is a pastoral issue and the couple should discuss this with their parish priest.

There are, however, other aspects of the in-vitro fertilization process, which may or do run counter to our church’s teaching.

• First of all, it divorces procreation from the conjugal act and should not be considered to be a normative practice. Yet, in-vitro fertilization could become standard practice due to certain selective benefits mentioned below. The application of this technology in some quarters has also allowed the use of surrogate mothers, in some cases to relieve the wife of the burden of child bearing. The practice of using or being a surrogate mother is expressly forbidden by our Church. As a corollary to the above, it should also be stated that our Church expressly forbids a female or male Orthodox Christian to sell their eggs or sperm, respectively.
• Second, the process of choosing the most viable embryos, however well-intentioned, might be viewed as a type of eugenics, or selective breeding. Given the trajectory of genetic research, it is not inconceivable that the time may come when parents can ‘pick and choose’ the characteristics of their child, thereby engineering so-called ‘designer babies’. This is a very slippery slope.
• Third, the unused excess embryos are cryogenically frozen and stored for future use. However, over time these embryos may be in jeopardy of destruction. Since our Church teaches that each embryo is a ‘full person’, if any of these embryos are willfully destroyed, that act is tantamount to the destruction of a person.
• Fourth, embryos stored in birth control clinics have become a source material for stem cell research. Embryos are destroyed to retrieve the stem cells. (Stem Cell research is further discussed below.)

Abortion

“Abortion is an act of murder for which those involved, voluntarily and involuntarily, will answer to God”
1992 OCA Synod of Bishops’ Affirmations, “On Marriage, Family, Sexuality and the Sanctity of Life”—Abortion

Our Church teaches that the willful and deliberate act of aborting/discarding/destroying an embryo or fetus for the purpose of birth control is expressly forbidden. This is why our church is against using the so-called ‘morning after’ pill. The ‘morning after’ pill is a pharmaceutical compound designed and sold to prevent an embryo from attaching to the uterus.

The humanistic arguments for allowing abortions under certain circumstances, such as in the case of rape and incest, seem at least on the surface to be somewhat compelling and compassionate. Yet our church rejects these arguments. Why? Because no matter what the circumstances of conception, God is always present in the creation of a new person and that new person has just as much right to life as a person conceived in a more ‘acceptable’ manner. Again, if this embryo or fetus is deliberately and willfully destroyed, that act is tantamount to the destruction of a person.

Stem Cell Research:

Stem cells are cells in our body that are used to make and replenish other cells such as kidney cells, liver cells, brain cells, etc. These are referred to as Adult Stem Cells. When stem cells are obtained from embryos, they are called Embryonic Stem cells and have pluripotential properties. This means that Embryonic Stem Cells have the capability to become any type of body cell. A tremendous amount of research is being performed with both kinds of stem cells because of their vast potential for treating damaged or diseased cell tissue.

Despite the potential benefit that may come from this type of research, our Church does not support the use of embryonic stem cells for this purpose. The rationale is that the ‘harvesting’ of embryonic stem cells requires the destruction of the embryo. Human embryos are considered by our Church to be full persons. Destroying the embryo destroys the person.

While there have been recent advances in biomedical research involving the generation of stem cells without the destruction of an embryo, this research is in its very early stages of development. It will be many years before any viable therapies become available. Meanwhile, the biomedical research community still supports the experimental use of embryonic stem cells in order to more fully understand the biology and chemistry behind specific cell regeneration.

END OF LIFE

Debilitating Diseases, Permanent Incapacitation and Terminal Conditions

“All efforts to heal physical and spiritual sickness, to alleviate physical and spiritual suffering, and to prevent physical and spiritual death are to be supported and defended.”
1992 OCA Synod of Bishops’ Affirmations, “On Marriage, Family, Sexuality and the Sanctity of Life”—Sickness, Suffering and Death

Our human body is vulnerable to injury, disease, and the aging process. We may become temporarily incapacitated, permanently incapacitated, or face a terminal injury/disease. Our lives can be compromised, disrupted and changed. Dealing with these situations can bring hardships, confusion, anger, and depression, affecting the person who becomes ill, their family and loved ones. Yet our Church tells us that God is with us even in times of distress, if we reach out to Him and His grace.

Some individuals and families handle these types of circumstances better than others. Despite the challenges and difficulties that are brought to bear, these situations also create unique opportunities for family, loved ones, and those afflicted, to exercise love, compassion and understanding.

While medical advances have expanded our choice of available treatment options over the past 50 years, there are limitations. There are circumstances beyond the power of medical science to heal; or which render us incapable of choosing or exercising our options, such as in a comatose state. Consequently, it is important that we prepare ourselves for the possibility of this type of situation.

Any prolonged illness or injury will always have both physical/biochemical and spiritual dimensions. The spiritual component manifests with urgency when a person faces permanent disability or terminal illness and must come to terms with his/her mortality. While much has been written about dying and death, there are no customized guidelines. Each of us will face our impending death in our own way. However, some things can be said about this ‘final’ time of our life on earth, if we are willing to face the fact that as our biological existence comes to an end, we can prepare for our transition out of this world and into the hands of God.

A myriad of concerns may confront us when we face our mortality and impending death. Instruction and guidance for the decisions to be made at this time are included below.

Living Wills

A living will, when carefully assembled and executed, addresses one’s personal, emotional and spiritual needs, as well as one’s medical wishes. A living will, when signed and notarized, becomes a legal document recognized by most states of this country. Essentially, a living will designates one’s Primary Health Care Agent and Alternates along with their specified authorities; describes the terms of Life Support; states the kind of pain/condition management a person wants to have; and details what the person wants their family to know concerning their illness and/or death. Further, in order that a Living Will be respected, it usually is necessary to appoint a person who has “durable power of attorney for health care purposes. An excellent document entitled “Five Wishes,” details the process of assembling a living will, and is available from Aging with Dignity [1-888-594-7437].

A living will benefits the person who has a debilitating or terminal illness and also relieves the person’s family from having to make difficult decisions without knowing the person’s wishes. The creation of a living will can be viewed as a charitable and loving act because it fosters an environment of death with dignity and consideration for others.

Hospice and Palliative Care

Hospice Care, as opposed to Nursing Home care, is for persons who have entered the end-stage of a disease. Hospice care is typically associated with end-stage cancer but in actuality provides care for many other end-stage diseases, including heart and liver disease, Parkinson’s disease, and many others.

The care provided by a Hospice Center is not curative in nature but palliative. Palliative care is the active treatment of uncomfortable symptoms, such as, pain, distress and nausea. A proactive and integrated approach to care giving, Hospice Care encompasses the patient and their family. While Hospice care is not curative, it is caring and supportive.

It should be the goal of both the family and the designated care givers to insure, as best as they can, that the final days of a terminally ill person are spent reasonably free of anxiety, tranquil and aware to the extent possible. Integral to maintaining this type of condition is the administration of pain medication. Given the wide range and sophistication of pain medication available today, there is no reason for a person to suffer from debilitating pain.

Artificial Life Support

“Extreme caution is to be exercised in decisions involving medical treatment, especially in the face of death. Extreme care is always in order to find the “royal path” between providing all necessary healing measures and merely prolonging the biological functioning of organs when human life is no longer possible, or even present.”
1992 OCA Synod of Bishops’ Affirmations, “On Marriage, Family, Sexuality and the Sanctity of Life”—Sickness, Suffering and Death

The development of Artificial Life Support (ALS) also made tremendous advances during the latter part of the 20^th century. These technologies, when properly and appropriately used, provide temporary body functions enabling a person’s body to heal itself and return to normalcy. Many are sustained by ALS assistance while they are waiting for a suitable transplantable organ (see Organ Donation, below). ALS is generally not regarded or proscribed as a permanent situation or solution. Two of the more common ALS methodologies, which in recent times have become somewhat controversial in life/death decisions, are Respiratory Assistance (Ventilator) and Tubal Nourishment and Hydration.

ALS methodologies, when chronically used on a terminally ill and dying patient only serve to delay and prolong the dying process. The decision to remove all life support and to let a loved one pass into God’s hands, while very difficult and emotional, is necessary in order to allow the person to make his/her transition from this world to the next. Arriving at this decision need not be, nor should it be undertaken, alone. The decision to remove ALS should take place after consultation with the person’s physicians and in counsel with one’s parish priest. Most importantly, this decision should take place in communion with God through prayer, asking for His guidance and help during this most trying and grief-filled time.

Deep Coma, PVS (Persistent Vegetative State) and Brain Death

A person in a deep coma or Persistent Vegetative State (PVS) presents a number of issues that concern our Church. The first consideration is whether the person is technically alive or dead. The answer to that question determines what ALS technologies should be used or not used.

Our Church continuously acknowledges Life and its attendant Sacredness. Where there is a clear chance of recovery, all medically available technologies should be used to support the life of the ill or injured person. On the other hand, if the person is terminally ill or gravely injured from which recovery is not expected, then to use ALS technologies to simply prolong the dying process, is basically immoral. It is important as Orthodox Christians to always keep in mind that “Death has lost its sting.” As sad and grievous as the death of a loved one can be, we as Orthodox Christians also know that while biological life may end, our Life Eternal with God continues.

In deep coma and PVS situations, the criterion for life is brain activity within the cerebral cortex. It is activity in that region of the brain that defines the human condition. It is the place where decisions are made, organization takes place and speculative activities such as creative arts and philosophizing occur. In the absence of any activity in this region, the attending physician(s) will declare the person as ‘brain dead.” Our Church recognizes and agrees with this conclusion. There is no rationale for the continued use of ALS systems to maintain a biological entity when no life force is present. Furthermore, the continued use of ALS may also make it difficult for the soul to leave the body.

The Dying Process

“Those who suffer, and those related to the suffering, are to be helped to find God in their affliction, and so to acquire the divine grace and power to transform their pain into a means of purification from evil, illumination from darkness and eternal salvation in the age to come.”
1992 OCA Synod of Bishops’ Affirmations, “On Marriage, Family, Sexuality and the Sanctity of Life”—Sickness, Suffering and Death

Generally speaking, there are two different but interrelated dynamics involved in the dying process: the physical shutting down of the body and the activities taking place on the spiritual-emotional-mental plane. No two people, if they are conscious and aware, manage the spiritual-emotional-mental activities in the same way.

As the body begins to shut down, there is a corresponding change in a person’s metabolic and circulatory processes. This will result in certain natural signs and symptoms, such as, congestion with gurgling sounds, restlessness, incontinence, and increasing coolness in the hands, feet and legs, to mention a few. Further, most people, when they are told that they are dying, deal with it in stages. Elizabeth Kubler Ross describes five stages in her book, Death and Dying: Denial, Anger, Bargaining, Depression, and Acceptance.

On the spiritual-emotional-mental plane, the person is preparing to detach not only from this world of ‘things’ but also from important relationships. As a consequence, many a person has recognized certain unresolved issues and/or unfinished business. Usually, this type of situation makes it difficult for the person to let go. Many times, restlessness is indicative of this type of situation. The Hospice team can help a family identify the issue and in turn may be able to help the dying patient come to final resolution.

In the final stage and time before death occurs, the greatest gift that we can give to the patient is Love and the greatest gift that the dying patient can give to their family is Love. It is worthwhile to remember that hearing remains all the way to the end. Speak to your loved one in a soft tone of voice, identify yourself, gently hold the person’s hands and say whatever you need to say to help the person to let go. And, by all means shed tears without hiding them from your loved one. Tears express our love and help us to let go.

Quality of Life, Euthanasia and Medically Assisted Suicide

“Scientific research and experimentation are to be undertaken with extreme caution in order not to bring greater evils and sufferings to humankind in place of intended blessings.”
1992 OCA Synod of Bishops’ Affirmations, “On Marriage, Family, Sexuality and the Sanctity of Life”—Sickness, Suffering and Death

The term euthanasia originally was used and understood to mean a “good death.” However, in current times it has come to mean ‘to put an end to a person’s life by a specific act.’ The Orthodox Church cannot and does not support such actions whether it is executed by the patient (suicide) or by any other party (individual or physician assisted suicide), even if the rationale is based on the ‘relief of suffering.’

There is the issue of removing life support systems from a terminally ill patient, which some have described as a form of passive euthanasia. While a terminally ill patient is generally described as someone who has been diagnosed as having only 6 months or less to live, the physical state and palliative care, including ALS, will vary greatly during that time period from the so-called beginning to the end. However, rather than a time window, it is better to view this situation from the standpoint of the dying process, wherein the body has initiated irreversible biological processes that will lead to imminent death. Under these circumstances, our Church is not against the removal of Artificial Life Support when it is agreed that the continuation will not lead to any demonstrable benefit and it is consistent with the patient’s desires.

Preparation for the Funeral

Strictly speaking, funeral preparation is not a medical bioethics issue, but it is a related issue. It is an event arranged with thought and cares by the family and is part of the letting-go process. However, since this is emotionally difficult, arrangements are usually delayed until after the inevitable has occurred and the person has died. For those who are inclined to prepare for their funeral ahead of time and in concert with their family, there is a wealth of information available on the internet. A very good and detailed funeral planning document can be found on the web site: www.funeralplan.com.

Cremation

The Orthodox tradition of burying its dead is the normative practice of our Church. However, there has been a resurgent interest in cremation in recent decades. While there are no canonical or dogmatic traditions prohibiting cremation, the common practice of cremation, at least in the Roman Empire under the influence of Christians, was abolished in the 5^th century. In general, the Orthodox Church has considered cremations in lieu of burial a dishonoring of the dead. This is in accordance and consistent with Christ’s death, burial and subsequent resurrection. Consequently, an Orthodox Christian lives in anticipation of Christ’s second coming and the resurrection of our bodies. However, it is important to realize that our resurrected body is not considered to be a ‘physical’ body but to be our ‘spiritual’ body. Thus, it follows that the lack of a physical body, such as in the case of total destruction in a fire or explosion, in no way affects a person’s salvation.

The most pertinent reasons for our Church’s practice of burying its dead rests not only on the fact of Christ’s death, burial and resurrection but also on our Church’s teaching that there is a continuity between the ‘living’ and the ‘dead’. The physical body demands respect because it is considered to have housed the ‘temple’ of God and as such, it too is worthy of remembrance. This is clearly demonstrated by the bodies of the Saints whereby they have exhibited clear signs of sanctification and holiness after their death. Further, it is our Orthodox Church’s practice and tradition to have memorial services at the cemetery over the body in remembrance of our departed loved ones.

There are situations wherein certain countries (Japan) and certain states (Louisiana) require cremation by law. In such cases the law is to be obeyed. However, the ashes should be placed in an urn and buried in a cemetery. In all other cases, the Orthodox practice of burial should be followed.

Organ Donation

There are two opposing theological viewpoints within the Orthodox Church regarding the donation of one’s body organs upon death.

First there is the view which maintains that since we are all created in the image of God, the harvesting of organs should be considered a form of mutilation and be thereby prohibited by the Church.

The other perspective is that there is no greater gift that a dying person can give than to donate a vital organ(s) so that someone’s life may be improved and/or prolonged. In fact, it might even be said that we are morally obligated to provide these organs, which we will no longer need, as a gift of unconditional brotherly or sisterly love for our neighbor.

Some express the fear that the bodies of humans will be viewed as simply a source of ‘spare parts’. This is hardly the situation, at least in this country, whereby Hospital and Medical Centers go to great lengths to insure informed consent; that is to say, a person’s organs upon death are not be taken without the expressed written consent of the patient. If an Orthodox Christian has died without leaving written consent to remove his/her organs, they should not be removed.

Summary

“Human beings are to be reminded by every means that they are not isolated individuals but are members one of another who will give account to God and to their fellow creatures for their every thought, word and deed; and that their eternal destiny depends on what they have done with their lives on earth.”
1992 OCA Synod of Bishops’ Affirmations, “On Marriage, Family, Sexuality and the Sanctity of Life”—Sickness, Suffering and Death

This synopsis of some of the more important medical bioethical issues facing us today as Orthodox Christians is not intended to be a complete presentation of all the issues and topics nor should it be considered an official document. Rather, it is intended to spark thought and discussion with regard to medical bioethical considerations and decision-making. For a more exhaustive treatment of these topics and issues, the reader is referred to and encouraged to read the following books by Fr. John Breck:

• John Breck, Stages on Life’s Way: Orthodox Thinking on Bioethics, St. Vladimir’s Seminary Press, Crestwood, NY (2006)
• John Breck, The Sacred Gift of Life: Orthodox Christianity and Bioethics, St. Vladimir’s Seminary Press, Crestwood, NY (1999)

The behavioral and moral dilemmas that we face and will face as medical and scientific technologies rapidly emerge in the 21^st century are complex and demand deep consideration. Much of what is and will be available to physicians as the result of medical research represents great benefits to humankind. The tremendous advances in cardiac care, such as therapeutic protocols for heart attacks and innovative surgical techniques used to correct heart artery/valve problems, are only one of the many areas of medical advancement/achievement that have improved the quality and length of human life. On the other hand, the medical frontier becomes a slippery slope when medical research and practices are found to be in stark opposition to the core tenets of the Orthodox Church and its teachings.

This document was prepared by Protodeacon Andruchow for parish presentation and discussion at St. Nicholas Church, Salem, MA. Reprinted by the OCA Department of Christian Service and Humanitarian Aid with permission.