Managing the end of life is challenging both for patients/families, and also for physicians. Join us as Scott interviews Dr. Ryan Nash, who has dealt with thousands of patients and families at the end of life as he shares his expertise on end of life care and assisted suicide.
More About Our Guest
Dr. Ryan Nash, MD, is Associate Professor of Medicine and Director of the Center for Bioethics and Medical Humanities at Ohio State University School of Medicine. He also serves as the Hagop S. Mekhjian, MD, Chair in Medical Ethics and Professionalism and he has a faculty appointment in the Department of Internal Medicine with ongoing clinical work in the Department of Palliative Medicine. Dr. Nash has a strong background in ethics and palliative care, researching how medicine, moral philosophy and moral theology impact patients with advanced and serious illness.
Scott Rae: Welcome to the podcast, Think Biblically: Conversations on Faith and Culture. I'm your host, Scott Rae, Dean of Faculty and Professor of Christian Ethics at Talbot School of Theology at Biola University.
We're here with our guest today, Dr. Ryan Nash, who is a palliative care specialist physician and Director of Bioethics and Ethics Education at the Ohio State University Medical Center in Columbus, Ohio, one of his specialties being in palliative care, I think, makes him especially well qualified to talk to us about our subject today, which is assisted suicide and its impact on the practice of medicine. So Dr. Nash, also a native Texan, having grown up in Houston myself, is great. It's great to have you with us. Thanks so much for joining us.
Ryan Nash: Thank you, Scott.
Scott Rae: So tell me, just in general, how does your Christian faith inform your work as a physician and your work in bioethics?
Ryan Nash: Well, I think right now in medicine there's a lot of traction on a concept of moral distress and burnout, compassion fatigue. It's common. I think it's a misdiagnosis. What moral distress really is, was defined in war when soldiers were told to kill or drop napalm on this village, and it was something they knew was wrong and they had to do it under orders.
I don't think that's what nurses and doctors are experiencing. I think they're experiencing the reality of sin and death and suffering in the world, and it impacts their soul. For non-believing physicians or medical health professionals, it's hard for me to understand how they do what they do without faith. When we get seasick, we're to look to the horizon. If there's no horizon, you're just tossed to and fro.
Scott Rae: You're seasick all the time.
Ryan Nash: You're seasick all the time. So I think one thing that especially dealing with patients with advanced illness, without the hope of Christ, without the reality of the soul with that reality of what death brings, that it is our birth into the true life, if we're united with Christ, without that mooring, I don't know how one could be a physician.
There are challenges, and I think that leads to the second part of the question. The challenge is we're in a greatly disoriented medicine, really medicine that it's hard to say if it was ever really oriented in a truly Christian way, but it's obviously increasingly not Christian or even anti-Christian. That makes it difficult sometimes being a Christian believer. I'm an Eastern Orthodox Christian, but nonetheless, very much that's central in my life. So in doing medicine, sometimes I feel constrained that I can't do all the things that I'd like to.
Scott Rae: Like what?
Ryan Nash: I can be clear on the proscriptions. I'll never participate in assisted suicide and euthanasia. I would never participate in abortion. I would never participate in gender reassignment. I would never affirm sin as such, but prescriptively, I think the Christian faith can offer even more. I'm not saying that you cheaply proselytize someone who's suffering and dying, but proselytizing doesn't have to be cheap.
Scott Rae: Right.
Ryan Nash: Sharing the hope that's within us, sharing that there's a need for repentance, that there's a need for contrition, that the prayer on our lips as we die is to be "Lord, have mercy on me, a sinner," and that the reality of meeting God when we die, I often feel constrained by secular medicine that I can't share in greater abundance, and I think I do more than most.
My palliative fellows often will comment after I go into, with permission, I go into depth with my patients on their faith and how that's important to them, and I've had sessions where I'm prescribing psalms for them to pray, and my fellows, usually not Christians, are just stunned. "What is this?" But they can't find fault because I had permission, and that's the great secular ethical principle.
Scott Rae: So you're prescribing psalms on your prescription pad and writing it out in your non-legible physician's handwriting.
Ryan Nash: Now it's all in the computer. But sometimes I will make a little note, and I don't prescribe psalms. I don't want people to think I'm overly righteous, but things like that, if we look at the long history, the Christian tradition of medicine before the modern era, before the enlightenment, if we look at the unmercenary Christian saints, they healed with medicine, with the best medicine of the day, largely [inaudible] medicine. They had surgery. Not in the kinds of technology we have today, but they did heal using those more mundane means, but they also used prayer and liturgical rites and anointing and confession. Most of them were priests as well. Not all, but many were priests, and they'd heal even miraculously.
That's a history that's largely unknown in contemporary culture, but when I read those lives, I long for something that would be ... One of the questions I have in my scholarly work is "What is Christian medicine? What will it look like? How would it look different than a secular medicine?" The proscriptions are clear. We're not going to kill. But the prescriptions are harder. "How do we encourage those that are hurting to be united with Christ?"
Scott Rae: And give them real hope.
Ryan Nash: And give them real hope that we can bring them to the true healer without it just being a simple, cheap intellectual assent, that it'd be something that actually tangibly changes them. So how do I deal with bioethics? Well, I try to do it on both ways, at both levels.
We have this secular level where I want to be honest as I am a clinical ethicist and an ethics committee chair and the head of ethics for a secular public university, I describe bioethics as it is, professional standards, legal standards, community standards. I describe it as it is, and often if I'm doing a clinical ethics consult, I may be giving guidance saying it's, at that level, this modus vivendi, this way of life, the way a peace among disputing parties. I can describe what's common in the practice while foundationally I know there's more.
Scott Rae: Right.
Ryan Nash: Now I try to influence that modus vivendi. Don't get me wrong. Sometimes I feel duplicitous or schizophrenic in the true meaning, but I try to influence in ways subtle and not so subtle, but I engage doing bioethics at both levels. At one level, doing the ethics that is a law and policy and public and community standards, professional standards, and then longing for and arguing for a better ethic that's normative or foundational. So I try to engage both.
Scott Rae: Okay. Ryan, you're a palliative care physician which, for our listeners who aren't familiar with that term, means you're a pain management specialist.
Ryan Nash: Right.
Scott Rae: And you deal with a lot of people at the end of life who are dealing with pain, in particularly endstage cancers, things like that. How do you understand the Bible's teaching on the end of life and our obligation to patients at the end of their lives?
Ryan Nash: Well, the Bible, with medicine, is largely ... I think there's more corrections in medicine, more examples of this woman with a flow of blood spent all over money on physicians, or there's often medicine did this, and now you've come for true healing. But I don't think in the Christian tradition, medicine has not been assured. It is permissible. I do think it's optional in the contemporary standard.
If a Christian wanted to forego medicine, I think that would have to be done with spiritual counsel and guidance, and it needs to be assured that they're not doing it for selfish purposes or for being in the throes of despondency or depression. Even though death is a great consequence of sin, general sin, the acceptance of death and longing for life in Christ that were birthed into true life, Saint Ignatius of Antioch, when he's ...
This is someone who was taught by the apostle John, the theologian, contemporary Polycarp and Clement. When he was going to Rome to be martyred, he wrote to the Romans, the Christians in Rome and said, "If you can stop this, don't, because I'm about to suffer the birth pangs of life." He saw his death as birth pangs, a consequence of the fall, the birth pangs of entering the true life. This isn't some sort of Gnosticism. This is entering into true life. This life, this biological life where body and soul are one is in preparation for the birth pangs, which is death and the separation of soul and body, then the reunion of them in the resurrection.
Scott Rae: In the resurrection.
Ryan Nash: This life is for preparation. I think that's the Christian view, is this life is for preparation. I do think we can use medicine to bring ... Saint Basil The Great in his Long Rule 55 says, "We can use medicine to bring longer life and better life." This is a bad paraphrase. "But once the person is consumed by illness or the treatment of illness and is distracted from zoe or the spiritual life, then we should set medicine aside," and I think that's fourth century wisdom that is lost, often, today where we have this in the cultural war theme, or if we have the mistake of viewing end-of-life issues through abortion politics, I think we can fall into ditches on either side of the way that is known in the Christian faith.
One ditch being discarding the sanctity of life and saying we can hasten death, we can cause death and assisted suicide and euthanasia, or neglect, I would say. The other is that because the culture of death that also furthers abortion, we have to uplift the pro-life banner, apply it to something that's not abortion and say, "We have to eke every second out of biological life as possible," even if this means great burden or non-beneficial therapy or a treatment delaying death by hours, days, when we know that death is coming and is inevitable.
I think that's a mistake, and it's a mistake that a lot of believing Christians, well-intended Christians make. I don't think medicine has to be used in all circumstance to eke every second out of biological life as possible. I think it is wise to use when it can bring healing and recovery. I think it is appropriate to use in patients with chronic illness or even terminal illness to a point. But once the patient is consumed with illness or the treatment thereof, I think it can be set aside.
Scott Rae: So the idea that death is a conquered enemy and need not always be resisted, and the idea that earthly life is not the highest good. It's a penultimate good.
Ryan Nash: That's right.
Scott Rae: Both of those, sound like, contribute to the avoiding that finalist extreme at the other end.
Ryan Nash: Right, and there's a book that I don't commend what's in it, but the title is pithy, that says Everyone Wants to Get to Heaven, But No One Wants to Die. Something like that. So, yes, biological life is secondary to the spiritual life. In scripture, the Greek term, zoe, is used usually when life-
Scott Rae: Not biological.
Ryan Nash: Not biological life, but zoe, the spiritual or ongoing life, is the main word for life. It's not the only one, but it's the main word for life, and we are too dismissive of that distinction. Biological life has value. We aren't Gnostic. We aren't Manichean. We don't hold this earthly life. We know that the world is dark, but that's the powers and principalities of the world. This world was created good. It is fallen. It's imperfect. We should long for resurrection in [inaudible], but biological life is finite, limited, and is not the ultimate goal. The life that is more abundant that they may have life and have it more abundantly is zoe. It's the ongoing life, the spiritual life.
Scott Rae: Now I take it that you're not a particularly big fan of physician-assisted suicide either for moral theological reasons or to see it legalized.
Ryan Nash: Right.
Scott Rae: Why not?
Ryan Nash: Well-
Scott Rae: What's the problem?
Ryan Nash: Multiple levels. I think from the Christian response, it should be fairly simple, that it's illicit. It's just not consistent with anything that's been in Christian tradition. It's not consistent with scripture. If you think of-
Scott Rae: Thall shall not kill, even by your own hand.
Ryan Nash: Right. The Texan would add a little asterisk and say, "Unless someone deserves a good killing," right? Which scripture also says in different ways. Now, that aside, whether that's true in the-
Scott Rae: God's prerogative.
Ryan Nash: Yeah, whether execution is permissible, I think is, especially in a secular government, I think that's a harder question to ask. I say it tongue in cheek, but you think of even the Malachi command coming to King David saying that he saw King Saul dying, and that with Saul's request, he took Saul's sword and ran them through. And what is King David's response?
Scott Rae: Not good.
Ryan Nash: He rips his cloak.
Scott Rae: Yeah.
Ryan Nash: Goes and mourns and weeps and prays and comes back and sentences him to death saying, "How dare you kill God's anointed. This is not your life to take." And this was his enemy. He had brought Saul's kingly garb to him, thinking he would get favor. He was lying, probably, because other parts of scripture says that's not how he dies, but scripturally I think it's fairly simple that it's illicit, it's prohibited. We can't do it.
Scott Rae: So why is it a bad thing that it be legal?
Ryan Nash: We don't proclaim a private gospel. Though I observe that we live in a post-Christian culture, and since at least the 1970s at law, the United States has been a very secular country, we still know that there are all kinds of ramifications and evil when sin is called good. Now, whether we use secular language to resist the legalizations of things that we know are bad for people and for society, or whether, I think, increasingly we should use explicitly religious arguments because I think the secular arguments have not won the day. They've been tried time and time again, and I think we should actually take a note from the religious minority movement saying, "We hold this."
If we look at Orthodox Jews, they usually don't say that "This is bad based on the natural law or these rational principles that have been extracted from our faith." They say [inaudible]. Same with Muslims. I think Muslims get a pass on many ethical issues in the secular society because they unashamedly say, "Well, this isn't how we do it."
Scott Rae: Right.
Ryan Nash: And when challenged, they just say, "That's not how we do it." Christians tend to want to use the humanist language that I think partly got us into this predicament. So we know that there are all kinds of problems that if society begins to kill the infirm, the suffering, hastening their death in such ways and call that compassion, then we have a perverted view of compassion indeed, in my experience. So I have a practical, I've cared for over 6,000 patients with terminal illness. I've been at their bedside. I've been with their families. I've never needed assisted suicide or euthanasia.
Scott Rae: Not once?
Ryan Nash: Not once.
Scott Rae: Not once in order to control their pain?
Ryan Nash: Well, I wouldn't try to control. I think that's the issue. I don't think my burden as a physician is perfection. I don't think it's my goal to have a completely still, lifeless body while they're still alive, which I think, increasingly, there's a trend in medicine and palliative medicine that may be the goal.
Scott Rae: We use the term terminal sedation.
Ryan Nash: Yeah, terminal sedation and now it's-
Scott Rae: Sleep until you die.
Ryan Nash: Right. So now people are calling a palliative sedation, and I do think there are some times that palliative sedation could be allowed. If someone's not eating or drinking. They're, to use the Texas term, fixing to die, and that they're going to die in the next coming hours to days, as best we know, and there's nothing you can change. You can't change that, and they have refractory symptoms. I think it's ethically permissible. But in 6,000 patients, I've maybe thought of using it twice, and I didn't.
I've never needed assisted suicide. If we just have a bit of patience, patients with terminal illness indeed do die. I do think you can forego other treatments. Although most of my patients, they're not making a decision about forgoing, they've had surgery and radiation and chemo, and they're dying anyway. There's not a big decision to make. We think about everything in a big decision, but a lot of it is that death is clearly coming, and we're acquiescing, reluctantly accepting that death is here.
That's the vast majority of the 6,000 patients I've cared for. A few have said the burden of that treatment is not worth the benefit, and I think that's consistent with the Christian understanding, as long as it's not selfish. Christians are called to surfer all kinds of burdens for the faith, but they're not called to suffer burdens that aren't ... All burdens are not all equal. I won't go off on that tangent too long.
Scott Rae: Yeah. Well, I love the proponents of assisted suicide make the argument that it's actually inhumane to deny terminally ill patients that choice, particularly if managing their pain is a bit more challenging. Somebody like Brittany Maynard, for example. She had this brain tumor. She was going to be afflicted with uncontrollable seizures, and she chose simply to have assisted suicide. Moved to Oregon to do that, just for our listeners who aren't aware of her situation. What would say to the person who says, "It's inhumane not to have that as an option for people"?
Ryan Nash: The simple answer would say, "I think it's a wrong definition of inhumane." Just like I said something about the wrong definition of compassion. To be truly human is to be in Christ. To follow a humane path is to follow the path of Christ. But I think in secular argument, I think we can actually use the example of Brittany Maynard to give the counter potential. The narrative that's often given is people need this choice in order to affirm and validate their wishes, and if their wishes aren't followed, that's torturous. That's just torture that they're suffering because you won't validate and affirm their wishes, and that's perverted in itself, right.
But let's imagine the case of Brittany Maynard. You have a young, attractive woman who's been made the poster for assisted suicide. She seems, at the time of her illness, seems that assisted suicide should be a right. She's convinced of that. What if she changes her mind? I often tell students, "Think about the way we approach burdens in medical care." If you asked Christopher Reeve when he was 33 in Superman to fill out an advanced directive and living will and ask, "Do you want to be a high cervical quadriplegic on a ventilator for the rest of your life?" He would probably say no way.
Scott Rae: Pretty sure he would say no.
Ryan Nash: Right. And when I ask an audience that question, they all say, "No way." But you ask them five days after he had his horse accident, and you say, "Mr. Reeve, we could allow you to die, take you off the ventilator, or you can fight for this. We will try to do rehab and we'll try to recover as much function as you can. We don't know how much you'll gain. You'll probably be on a ventilator for the foreseeable future." And he says, "I want to fight. I want life."
Now this happens in end of life care, too. You give up, especially if someone's older. You give them a diagnosis of lung cancer, and if you have them fill out what they want, they'll say, "Well, I don't want any heroic measures.I don't want to be a burden. I'm concerned." But then as they get sicker, they're more willing to accept care of others.
Scott Rae: That's a great point.
Ryan Nash: So when Brittany Maynard becomes the spokesperson for assisted suicide, and as she starts getting sicker and starts thinking, "Well, what if I don't want to commit suicide? Is that humane?" There's actually word that she had this.
Scott Rae: Oh, is that right? That she had second thoughts?
Ryan Nash: She actually had second thoughts. Her husband on the bank roll for Compassion & Choices.
Scott Rae: Oh, I think most people probably don't know that.
Ryan Nash: I don't know when the timing was. I don't want to give a false narrative. I don't know when the timing of that was. The society looking to her, the media following every detail of her dying narrative, if she said, "No, actually I don't want to," what does that do to the narrative?
Scott Rae: That's pretty damaging.
Ryan Nash: It's damaging, yeah. So you have dystopias like Soylent Green that have this, right? The B rate movie, your Charlton Heston movie that Soylent Green is people. It's not the book, but it's an interesting cult classic movie, but interesting book where it talks about the societal pressure to not be a burden on society. And if that message is there, what message does that send for the disabled, for the infirm, for the elderly? If we say, "Really, you don't want to be a burden. You have this other way out."
Scott Rae: Better off dead.
Ryan Nash: Better off. It saves society. It saves the family anguish, and you get control. Well, what if I really don't want that control, but I feel all kinds of undue pressure? So I think in that kind of case, you can use secular argument. Now, I think the Christian way would be so much better, that preparing the soul ... We live in an era filled with escapism. We use entertainment, we use technology, we use drugs, we use all kinds of things to escape. We're in the most prosperous culture in the history of the world as far as financial wealth and comfort, but we are so distraught and so despondent that we always want to escape.
I think assisted suicide is the ultimate escape. They're trying to control the very last bit so that they don't lose control over the final moments of their life, that they can somehow be the captain of their ship, the master of their-
Scott Rae: Up until the very end.
Ryan Nash: Until the very last. But there are other reasons why people will choose this, but the message for the Christian is that you can't escape yourself. You take your soul with you in death, that the soul that has been prepared, and this isn't a work salvation, I'm saying that soul that has been prepared in life, that soul goes with you with its same proclivities, its orientation to God or orientation where the lion of the lamb becomes a consuming fire because one will not accept the loving embrace of God.
If we can prepare people to prepare their souls for death, it would be far greater. Scott, it's really interesting if you ask Americans how they would want to die, they're generally going to say, "In my sleep and unexpectedly." But the church father said, and there's actually an ancient prayer that says from a unexpected death, "Oh Lord, preserve us," because they considered it a blessing to know that you're going to die, that you can prepare your soul in repentance and contrition, that at the moment of your death, you could have solemnity or the simple prayer of the publican, "Lord have mercy on me, a sinner," on your lips, and that was a good death. Not dying in your sleep unexpectedly or being sedated to oblivion so your family is not stressed, or killing yourself.
The Christian notion of killing yourself, the archetype is Judas. The ancient icon of Judas, the ground is cursed around him. This is a horrific way of dying and had all kinds of ramifications in church history as well, when people would commit suicide.
Scott Rae: Ryan, this is so rich. I don't know of any other physician who is as theologically well grounded and astute as you are in applying this to the details of medical practice. I suspect for many of our listeners, this may be the first time they've heard a physician who is so theologically good. So I really appreciate the depth that you bring theologically to this. It's so well framed, so well grounded.
Let me ask one final question, if I might. In the next 20 years we're going to have a record number of people over the age of 65 in our healthcare system. Already Europe, we're seeing people connect advocacy for assisted suicide with this demographic landslide, sort of under the heading of "There's nothing cheaper than dead." What do you anticipate here? How's the healthcare industry going to deal with this while at the same time keeping assisted suicide, we hope, off the table?
Ryan Nash: I think assisted suicide will grow, and I think voluntary active euthanasia, which I think morally is equivalent ... It's not quite the same, but they're moral equivalents, I think. If I give you counsel to take something and you'd take it yourself, there's not much difference in me giving you the drug directly. There's one active consent that you could always change your mind with suicide until you take it. Although, after you've taken it, you could still change your mind, but not be able to undo it. Because you're definitely morally culpable in either, I think there will be a push for voluntary active euthanasia.
Looking at Canada as the great experiment, I think voluntary active euthanasia will be much more popular in Canada than assisted suicide is in the United States because there's something about medicine blessing this, right? And if medicine blesses the suicide, that's one thing. But if medicine you can go in for a procedure and yo die, my view is that medicine has become a moral authority, falsely, wrongly, for Americans.
Marijuana becomes good if it's medical or homoeroticism or gender identity, people look to medicine for the morality instead of to the church. This is a problem. So I do think voluntary active euthanasia will become legal in the US, although my prediction abilities, I don't have [inaudible]. I don't-
Scott Rae: You don't claim to be a profit.
Ryan Nash: I don't. I don't claim. I was wrong in the 2016 election. My life predictions, I should probably not make as many. The Silver Tsunami that's hitting. A couple of things. We've been told for decades that healthcare is non-sustainable in the US, but it keeps on sustaining. Now we're just hitting the beginning of the Silver Tsunami. We're in the midst of it. It's going to continue to grow and swell.
There is a unique economic structure that because healthcare is becoming such a large part of our economy that in some ways you're feeding a micro economy that, well, yeah, there's a Silver Tsunami of increased patients, but there's increased nursing jobs and health tech jobs and physician jobs and insurance jobs, and there's this whole economy created that I think, in some ways, may sustain it some way. Health reform, if you make it all under Medicare for all or something, I think then you start seeing the burdens of the European system that if it becomes a right, it may not set the same kind of micro economy.
I don't know what's going to happen. I can say that there'll be increasing pressures for putting caps on non-beneficial care. I don't think all of those caps are bad. I think truly non-beneficial care should not be covered and medicine should. Paternalism is a funnily funny term. I'm a pater. I'm not a tyrannical despot. I don't care what my daughters say, but I'm a father, and paternalism, if it's loving and wise, is not a problem. The problem in medicine with paternalism was it wasn't necessarily loving and wise, and insurance companies or government regulators may not be loving and wise either. So in theory, I may not be opposed to prohibitions of non-beneficial care, but you want to be really careful who's making the rules, and we should be attentive on those.
I do think we will have a push for palliative care in certain circumstances. I think this is partly societal, that in the aging population that there may be a subtle or not so subtle push to say, "Are these the droids you're looking for? Are these the technologies you really want? Is this the way you want to live your life?" and a societal pressure not to undergo. At the same time, we're having a technological boom where there are chemotherapy regimens that aren't making people as sick as they used to and bringing much greater life expansion than I would've predicted a decade ago even.
Scott Rae: Wow. There's a lot to think about here, especially as the baby boomers start to age and we get closer and closer to that becoming a reality. It'll be interesting to see what happens to the prevalence of assisted suicide and volunteer active euthanasia as that time comes along. Ryan, thank you so much for hanging out with us here. I so appreciate the theological depth with what you bring to the practice of medicine, and I'm sure your patients are richer because of it, and your own soul, I think, is richer because of that, too.
Ryan Nash: Well, you're not helping my attempt to walk in humility, but it's a joy talking with you, Scott.
Scott Rae: It has been just delightful to have you with us. I hope for our listeners, I think it's going to be a while before you hear from physician who is this good theologically. So thanks so much for being with us.
Ryan Nash: Happy to come by.
Scott Rae: Really appreciate this. This has been an episode of the podcast, Think Biblically: Conversations on Faith and Culture. To learn more about us and today's guest, Dr. Ryan Nash, and to find more episodes, go to biola.edu/thinkbiblically. That's biola.edu/thinkbiblically. If you enjoyed today's conversation, give us a rating on your podcast app and share it with a friend. Thanks so much for listening, and remember, think biblically about everything.