Most of us who have watched the Terri Schiavo tragedy unfold have wondered what to think. The legal issues involved in her medical care and death are enormous. When should society guarantee a person's right to refuse life support? What kind of statements and/or documents are necessary? Absent these, is the decision best left to the spouse or other immediate family? What role should health care providers play?

Nearly every person I've spoken with on this subject says that he or she would not wish to be kept alive under such circumstances. Nearly every parent would want a role in making such a tragic decision. The legal and political issues raised by this tragedy will be discussed for some time to come.

However, my interest in this essay is not legal but biblical. I'm writing to try to clarify my own mind on this difficult subject, and perhaps help others as they wrestle with this tragedy. Unfortunately, any of us could find ourselves where Mrs. Schiavo's family has been since 1990. Perhaps this essay could help answer some of the hardest practical and theological questions raised by this painful issue.

Let's begin with a brief description of terms used by the media as they have covered this tragedy.

"Euthanasia" is derived from the Greek word "eu" (well) and "thanatos" (death). It usually means a "good death" or "mercy killing," and is understood to be the provision of an easy, painless death to one who suffers from an incurable or extremely painful affliction. Such an action is considered valid only when the suffering person wishes to die, or is no longer able to make such a decision.

A distinction is usually made between "active" and "passive" euthanasia. Active euthanasia occurs when actions are taken to produce death. This is often called "assisted suicide," as in the actions of Dr. Jack Kevorkian and others who have provided medical intervention which led directly to death. "Passive" euthanasia occurs when the patient is treated (or not treated) in a way which is intended to lead to death, but medical measures are not taken to cause death directly.

A third category has become common in recent years. "Letting die" signifies the decision to approach medical care so as to enhance the patient's well-being during the dying process. Unlike passive euthanasia, the doctor does not intend the patient to die as a result of this decision. Rather, the doctor withholds medical treatments which intensify suffering or merely postpone the moment of death for a short time.

For instance, it is not considered passive euthanasia to discontinue chemotherapy in cases of advanced cancer, especially if the drugs increase the suffering of the patient. The doctor does not intend this decision to cause death, even though death may result from his action.

In these terms, Terri Schiavo's death resulted from passive euthanasia, as physical sustenance was withdrawn for the purpose of ending her life. Food and water were not considered to heighten her suffering, as would chemotherapy. Their removal was intended to lead directly to her death.

The decision to enact passive euthanasia is termed "nonvoluntary" since Mrs. Schiavo could not express her wishes. However, her parents could call the decision "involuntary," believing that it went against her wishes as they believed she would have expressed them. Her death would have been "voluntary" if she had given "informed consent" while motivated by her own best interests (unlike a person suffering from mental or emotional illness who wishes to die).

If Mrs. Schiavo had executed a "durable power of attorney," she would have signed over all responsibility for her medical decisions to another person, usually her spouse. Because she did not take this action, the court gave her husband responsibility to make medical decisions for her, a decision known as "substituted judgment."

Maintaining Terri Schiavo's life would have required "heroic" or "extraordinary measures." Some patients wish only "ordinary means" which offer reasonable hope of benefit and are not excessively burdensome. A third means of support could be called "basic," providing only nutrition and water.

The doctors treating Mrs. Schiavo were required to help their patient ("beneficence") and to refrain from harming her ("nonmaleficence"). They could ethically provide medical assistance to alleviate any suffering, even if such help shortened her life. This "double effect principle" assures that doctors do not act immorally if they intend only the good effect, do not use bad as a means to good, and create good at least equal to the bad. For example, doctors can prescribe morphine to alleviate the suffering of a terminally ill patient, even if a side effect of morphine in that patient will shorten the person's life, unless they intend the drug to shorten or end that life.

Medicine has usually defined "death" to occur with irreversible cessation of circulatory and respiratory function, or with the irreversible cessation of the whole brain. But what is "brain death"? The "upper brain" supports consciousness, while the brain stem controls body functions such as breathing and heart rate. If the upper brain has died, the patient is considered to be in a "persistent vegetative state" (PVS). There are estimated to be 10,000 PVS patients in the United States. This was reported to be Mrs. Schiavo's condition.

If the brain stem has also died, the patient is considered to have suffered "brain death." Because nerve cells do not regenerate, upper-brain and brain death are completely irreversible.

In cases of PVS ("persistent vegetative state" caused by upper-brain death), what medical options could be considered scriptural? What does the Bible teach regarding the larger subject of euthanasia?

First, let's make clear that active euthanasia or "assisted suicide" is unbiblical. This practice is the overt, intentional taking of life, and is prohibited by the Sixth Commandment (see "suicide" discussion below). For the remainder of this essay, we will consider euthanasia only as the subject relates to passive or "letting die" options.

Ethicists seem to agree that in cases of total brain death or upper-brain death, "heroic" measures are unnecessary. Many believe that ordinary treatment is not obligatory, and "letting die" is moral. Some, however, believe that it is wrong to withdraw food and hydration, allowing the body to starve. This approach views the life as "holistic," meaning that a functioning body is still united to the "soul," the "image of God." Such a person is still a member of the human race, and deserves at least basic care (food and water), if not ordinary care (routine medical support).

Other Christians believe that brain-dead or PVS patients are simply bodies, that their souls or spiritual selves have gone on to eternity. Withdrawing food and water from such patients is then considered to be morally right. In this view, without a functioning brain, the body no longer sustains a soul or retains the image of God. Medical personnel should always care for those who possess potential for conscious life. But when a PVS exists, there is no possibility of brain regeneration and the "soul" has left the body.

Still others support "vitalism," the belief that physical function by itself is sacred. In this view, even if the "soul" has departed a body which is brain-dead or in a PVS, the body deserves medical treatment to the very end of physical life. Some "vitalists" support ordinary care or basic care for such a body, while others argue for heroic means to preserve physical function as long as possible.

In these terms, Mr. Schiavo's decision to withdraw food and water would reflect the belief that his wife's soul had departed her body, and that ending basic care was morally right. Given his insistence that this decision reflected her wishes, his directive was followed by her physicians.

Which view is the most biblical?

One approach to answering our question centers in the scriptural description of humanity as created "in God's image." Genesis says that "God created man in his own image, in the image of God he created him; male and female he created them" (Genesis 1:27). What does it mean to be in God's "image"?

Most theologians would center their answer in humanity's uniqueness. What is it which separates us from other life? Such characteristics make us uniquely "the image of God." Four biblical statements are connected directly to this phrase and identity:

1. We are created in God's image to "rule over" his creation (Gen. 1:28).
2. The Lord warns us, "Whoever sheds the blood of man, by man shall his blood be shed, for in the image of God has God made man" (Gen. 9:6).
3. Paul instructs a man not to "cover his head" in worship, "since he is the image and glory of God; but the woman is the glory of man" (1 Corinthians 11:7).
4. James criticizes the fact that "with the tongue we praise our Lord and Father, and with it we curse men, who have been made in God's likeness" (James 3:9).

From these specific biblical references to the "image" or "likeness" of God we can suggest that a person retains this "image" when he or she is able to relate to the rest of God's creation as his representative on earth. We are to "rule" or govern creation, represent God to others, and value each other. In this sense we may be created not so much "in" the image of God but "as" his image on earth.

By this reasoning, we lose the "image of God," that which makes us uniquely human and valuable, when we lose the ability or potential to relate to ourselves, our environment, other humans, and God. By this definition, a baby in the womb and a comatose patient are a person, in that they retain the potential for such interaction. But a PVS individual is not.

How does this distinction relate to the body? Some believe that the "soul" can depart the body before its physical death. This is typically considered the "dualistic" view, separating the physical and the spiritual.

Jesus cried from the cross, "Father, into your hands I commit my spirit" (Luke 23:46). Stephen prayed before his physical death, "Lord Jesus, receive my spirit" (Acts 7:59). Some interpreters use these statements to separate the soul or "image of God" from the body. In the belief that a PVS patient does not and cannot exhibit the image of God, it is then concluded that the person's "soul" has left the body. Any physical support for the body, even food and water, is thus unnecessary.

Others adopt a holistic understanding of the biblical view of humans. While the Greeks separated body, soul, and spirit, the Hebrews did not. It is not so much that we "have" a body, soul, and spirit which can be identified as separate entities. Rather, we "are" body, soul, and spirit. These words are different dimensions of the one person (cf. 1 Thessalonians 5:23).

In the holistic view, we retain the "image of God" so long as our bodies retain some dimension of physical life. Mrs. Schiavo's parents spoke passionately of the joy she continued to bring them, the love they felt for her despite her condition. They would argue, I'm sure, that she was still a "person" to them. In the holistic approach, so long as a person is alive physically, that person is the "image of God."

It may be concluded in this view that Mrs. Schiavo, as long as she lived, was a person deserving of basic physical support. Food and water are essential, appropriate provision for any person. And so the decision to withdraw them would be wrong.

What if she had previously directed that such withdrawal occur? Then the law would require that her wishes be honored. But should it? Should we be permitted to mandate that heroic or even ordinary measures not be taken to maintain our lives?

The dualistic view believes that a patient loses the "image of God" in certain medical conditions, and would support that person's previously stated right to refuse medical life support. The holistic view, taken to its logical conclusion, would seem to require at least food and water to be provided, in the desire to preserve and honor the "image of God." Some would argue that even heroic measures are required, and that a person should not be allowed to refuse them. Just as we require passengers in cars and airplanes to wear seat belts, so we should require patients to receive all medical support for as long as their bodies survive.

I believe the holistic view to reflect the biblical understanding of humanity. But I also believe a distinction between heroic, ordinary, and basic life support is warranted. In my view, it is permissible to cease heroic or even ordinary life support for a person who possesses no actual or potential capacity for relational life on any level, who cannot demonstrate the "image of God."

But I also believe that so long as the body is alive, the "person" is alive. And persons deserve at least basic (food and water) support, for as long as they live. Although the state allows us to choose passive euthanasia, medical actions which are intended to bring about our death, I do not believe such a decision is warranted biblically.

Let's assume that Terri Schiavo did in fact express her desire to refuse medical life support and even to experience passive euthanasia. Her husband and doctors then acted within the law in withdrawing food and water for the purpose of ending her life. But I do not believe she or they acted within biblical guidelines. In my view, we should not be permitted to request medical steps which are intended to cause our death. Absent our clearly expressed intention, our caregivers should not be permitted to choose such actions.

However, we and/or our doctors can choose to "let die," to take medical steps which do not prolong our lives. When these medical actions enhance the present quality of life, even if they shorten the life span for terminally ill patients, they are especially warranted.

On those heartbreaking occasions when I have been asked by a church member for counsel regarding the discontinuation of life support, I have encouraged the family to know that maintaining or ending medical care does not mandate or limit the intervention of God. The Lord Jesus raised Lazarus from the grave after he had been dead four days (John 11:38-44). He does not require medical life support to heal. And if it is his will that the patient not survive physically, no medical means can defeat his purpose.

The question, in my view, relates to intention. Does the family intend to hasten or even cause death? I do not believe such a decision to be defensible. On the other hand, do they wish simply to allow nature to take over, "letting die" if this is the natural result of the patient's condition? In this situation, medical support is not prolonging life--it is prolonging death.

If all medical options have been exhausted, and there is no plausible reason to believe the patient will ever improve, the family who ends heroic or ordinary life support is not removing the possibility of divine intervention. Rather, they are placing their loved one in God's hands, to heal physically or eternally.

Then the Lord will heal as he wills. He sometimes heals us physically, returning us to life in our fallen bodies on this fallen planet. But he eventually heals us eternally, taking believers from earth to heaven, from disease and death to paradise. Either way, we are well.

What does the Bible say about suicide? And is this term appropriate for a living will or other decisions which prevent life support?

God's word consistently warns us that suicide is always wrong. Deuteronomy 30:19 is God's command, "Now choose life, so that you and your children may live." Job knew that the Lord gives and the Lord takes away, that life and death are with God and not us (Job 1:21). Paul teaches us, "You are not your own; you were bought at a price. Therefore honor God with your body" (1 Cor. 6:19-20). And the sixth commandment is clear: "You shall not murder" (Ex. 20:13). Most interpreters include self-murder within this prohibition.

Despite this warning, Saul and his armor-bearer took their own lives (1 Samuel 31:4-5), as did Ahithophel (2 Samuel 17:23), Zimri (1 Kings 16:18) and Judas (Matthew 27:5). Given the character of these people and their act, the biblical materials seem to condemn their decisions. And the clear teaching of God's word stands against such a decision today.

In Mark 3, Jesus has just healed a demon-possessed man. The amazed crowds began to speculate that he might be the Messiah. His enemies retort that he drives out demons because he is in league with the devil himself. Our Lord responds with the most severe warning in the gospels: "whoever blasphemes against the Holy Spirit will never be forgiven; he is guilty of an eternal sin" (Mark 3:29). What did he mean? What is this "unpardonable" sin?

Know that Christians cannot commit this sin. 1 John 1:9 is clear: "if we confess our sins, he is faithful and just and will forgive us our sins and purify us from all unrighteousness." "All" means all. No sin is unpardonable for a Christian.

From Mark 3 we know that this sin relates to the work of the Holy Spirit with regard to unbelievers. Jesus is warning the Pharisees who rejected him that they are in danger of this sin. So what does the Spirit do with non-Christians?

He convicts them of their sin and need for salvation (John 16:8-9). He tells them about Christ their Savior (Jn. 15:26). He explains salvation (1 Corinthians 2:14). When they confess their sins and turn to Christ, the Spirit makes them God's children (Romans 8:9, 11). In short, the Holy Spirit leads lost people to salvation. So we know that it is the "unpardonable sin" to refuse this salvation. To be convicted of our sin and need for a Savior, but refuse to admit it. To be presented the gospel but reject it.

Why is this sin unpardonable? Because accepting salvation through Christ is the only means by which our sins can be pardoned. It is "unpardonable" to reject the only surgery which can save your life, or the only chemotherapy which can cure your cancer. Not because the doctor doesn't want to heal you, but because he cannot. You won't let him. You have rejected the only means of health and salvation.

The unpardonable sin is rejecting the Holy Spirit's offer of salvation, and dying in such a state of rejection. Then you have refused the only pardon God is able to give you. Don't do that. Be sure you have made Christ your Lord, today.

Why, then, is suicide so often thought to be the "unpardonable sin"? Not because the Bible ever teaches this connection. Here's the story in brief.

In the first era of Christian history, the Church came to separate "mortal" from "venial" sins. "Mortal" sins would condemn a person to hell, "venial" to Purgatory. Only by confessing a mortal sin could a person avoid hell. Murder, including self-murder, was one of these mortal sins. And of course a person could not confess this sin after committing it. So by logic, suicide was defined as the unpardonable sin. But nowhere does the Bible teach that this is so.

Suicide is always wrong, always a sin, and always a tragedy. It places far more grief and pain on family and friends than choosing life would have. It takes into human hands a decision which is God's alone. It leads to judgment and loss of reward by God in eternity. But it is not the unpardonable sin. Those you care about who committed suicide are not in hell for having done so. Rejecting Christ is the only unpardonable sin.

Is "suicide" an appropriate description for the decision not to provide medical measures of life support? The answer depends on the intent. Active and passive euthanasia, decisions to act in a way which produces death directly, are indeed a kind of suicide. But "letting die," making the patient comfortable even if such care may shorten life or honoring the patient's wishes not to be kept alive artificially, is not.

Jesus' willingness to die on the cross was not a suicide. The martyrdoms of the other disciples, all of whom could have prevented their deaths by denying Christ, were not suicides. It is not suicide to choose not to prolong death. We are within our biblical rights to instruct our families not to prolong life in the event of a tragedy such as PVS. But I do not believe we should instruct them to take steps which are intended to cause our death.

If you are facing a decision regarding life support, it may be helpful to know what the Bible teaches about death. Why do we die? What happens in the moment a believer dies physically?

According to God's word, death is inevitable. In fact, you and I are one day closer to death and eternity than we have ever been before. God's word warns us: "It is appointed unto all men once to die, and then the judgment" (Hebrews 9:27). Death comes for us all. Neither wisdom nor wealth can prevent it: "All can see that wise men die; the foolish and the senseless alike perish and leave their wealth to others" (Psalm 49:10). We all face the same end, unless Jesus returns first: "Why, you do not even know what will happen tomorrow. What is your life? You are a mist that appears for a little while and then vanishes" (James 4:14).

On a tombstone in Sevenoaks, Kent, England is found these words:

"Grim death took me without any warning
I was well at night, and dead in the morning."

It can happen that way for any of us.

Why does death exist? If God were all-loving, he'd want to destroy death, we assume. If he were all powerful, he could. But he doesn't. Why?

Here's the simple answer: because of sin. The thief on the cross said, "We are punished justly, for we are getting what our deeds deserve" (Lk. 23:41). The Bible agrees: "Sin entered the world through man, and death through sin, and in this way death came to all men, because all have sinned" (Ro. 5:12). This wasn't God's intention. He created a perfect world for his children. But when sin entered, death stayed. Death exists, not because God doesn't love us or isn't powerful, but because of sin.

Sometimes we die because of our own sin, as did the thief at Jesus' side. Sometimes we die because of the sins of others, as when a drunk driver kills a child. Sometimes we die because of the sin of humanity, for this is the lot of life on this fallen planet. But we all die.

God doesn't stop death, so that we'll not live forever in our fallen world and bodies. In Genesis 3 God knew that if Adam and Eve ate from the tree of life after their sin, they would live forever in their fallen, sinful condition. So in his merciful grace, he barred the way. Now by death, we are set for eternity with him.

God's word is clear: "Flesh and blood cannot inherit the kingdom of God, nor does the perishable inherit the imperishable" (1 Cor. 15.50). Physical death frees us to live forever in glorified bodies with God in his heaven. Then one day, death will be destroyed forever: "Death and Hades were thrown into the lake of five" (Rev. 20:14). His word promises: "There will be no more death or mourning or crying or pain, for the old order of things has passed away." (Rev. 21:4).

What happens in the moment when a person dies? First, we are with Christ, if Jesus is our Lord. Jesus told the thief at his side, "Today you will be with me in paradise" (Lk. 23:43). "Paradise" was a Persian word for the walled garden of the king. Not only would the thief receive eternal life, he would spend it with the King himself. Jesus taught us that the moment we die, the angels carry us to God's side (Lk. 16:22). When we close our eyes here we open them there. We will never die (Jn. 11:26; Philippians 1:23). We are forever and always with Jesus.

Second, we're home. Paul said, "We would prefer to be away from the body and at home with the Lord" (2 Cor. 5:8). Imagine a small boy who falls asleep in the back seat of the car. When the family gets home, his father picks him up and carries him into the house. When he wakes up, he's home. That's exactly what happens for God's children.

Third, death is glory. It is paradise, as Jesus said. Paul said "to die is gain" (Phil. 1:21), for "blessed are the dead who die in the Lord" (Rev. 14:13). We will gain imperishable, glorified, spiritual bodies (1 Cor 15:42-44), and be like Jesus (1 Cor. 15:49). We will know God and each other as we are known (1 Cor. 13.12). And we will eat of the tree of life and live forever (Rev. 22).

However, remember a fourth fact: death is eternal punishment for nonbelievers. So be ready now. The Lord said to King Hezekiah, "Put your house in order, because you are going to die" (2 Kings 20:1). If you are prepared, there is nothing to fear in death, for it is but the next step to life.

The famous evangelist Dwight Moody, on his deathbed, said, "If this is death, it is sweet. There is no valley here. Dwight! Irene! I see the children's faces. God is calling me. I must go. Earth recedes. Heaven opens before me."

If Jesus is your Lord, when you die you won't. Instead, you'll see God. And you'll be safely home.

I cannot imagine a future essay dealing with a more difficult subject than the issue we have discussed today. I'll summarize my own position regarding Terri Schiavo's tragic situation with the following statements.

First, I believe that persons retain the "image of God" so long as we possess the ability or potential to relate to ourselves, others, our world, and God. When such identity is irreversibly gone, no heroic or ordinary medical means of prolonging our physical lives are necessary or even warranted.

Second, I view humans holistically, believing that body and soul are one. So long as physical life remains, the inherent value of persons to their Creator and to others requires that they be provided at least basic support (food and water).

Third, any action which is intended to produce death, whether active or passive euthanasia, would be wrong. "Letting die," making the patient as comfortable as possible even if such medical procedures might shorten life, would be permissible.

Fourth, we have the right to refuse medical support if in the future we experience the irreversible loss of the "image of God." Such a decision is not suicide, but the determination to place our lives in the hands of God and the natural processes he created. We can direct our families not to prolong our lives in such circumstances. However, we should not direct our families to take steps which are intended to lead directly to our death. We should make such a decision known and legally clear to our family now.

Fifth, it is permissible to end medical support for persons in conditions such as PVS, whether or not the patient has made clear his or her wishes, so long as this decision is not intended to cause death. Prolonging death is not required by such circumstances.

As a result, I would disagree with the decision to remove Mrs. Schiavo's nutrition, as it was clearly intended to bring about her physical death. Even though he and her doctors acted within the law, I do not believe they acted within biblical guidelines. We are not required scripturally to prolong death, but neither are we permitted to cause it.

However, I recognize clearly the fact that I am writing this essay in a context completely different from the emotional hell which Mrs. Schiavo's family has endured. I have no desire whatever to appear callous with regard to their unspeakable pain, and in fact have prayed consistently for them through the decision to end her life, and after her death. I am profoundly grateful not to have been placed in their position, and grieve for and with them. I cannot imagine a more difficult situation than they have faced.

One final word: whatever our views regarding this most difficult subject, we who follow Christ as Lord must be the presence of Jesus to those who face such tragedy. Our first responsibility is not to tell others how they should act in these circumstances, but to demonstrate God's love and compassion in ours. Praying for Mrs. Schiavo's family and friends is now our most appropriate response to her death. We are to seek ways to support those undergoing similar tragedies, all the while inviting those facing death to know the One who gives life

And we are to be sure that we are ready for our own death, whenever it comes. Tomorrow is promised to none. But for all of us who have asked Jesus Christ to forgive their sins and be their Lord, his promise is ours: "whoever lives and believes in me shall never die" (John 11:26).

Richard Baxter, the great Puritan pastor, lay on his deathbed. A visiting friend asked the theologian how he was doing. Baxter turned, smiled, and whispered, "Friend, I am nearly well." May we each say the same today.