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.