Nearly 50 years ago, Lucy Bregman volunteered for two weeks in a residential mental hospital for the severely disabled, caring for people who didn't have the physical or social capabilities to participate in the outside world.
She walked along rows of adult cribs, hearing patients' gurgles and cries. She wondered about the families that left these men and women behind, and those, like the hospital's chaplain, who felt called to stay.
"The chaplain said he wanted to make sure even people with severe limits got some presence of God in their lives, even if they couldn't recognize it," said Bregman, who is now 71.
His words came to her recently as she reflected on faithful responses to medically assisted suicide. Bregman, who has been teaching Temple University's undergraduate "Death and Dying" course since the 1980s, knows that the world's religions offer many lessons on life's end. But, as that chaplain taught her, faith also reveals the inherent value of all human life, and it's this aspect of religion that is most meaningful for contemporary end-of-life-care debates, she said.
"Everybody has some limits, but maybe, at least in relationship to God, the difference between huge limits and small limits is not all that great after all," said Bregman, an Episcopalian.
In 2016, 16 state legislatures, including Utah's, have addressed or will consider legalizing medically assisted suicide, according to the Death with Dignity National Center. The practice is legal in Washington, Oregon, California, Montana and Vermont.
As faith leaders lend their voices to these legislative debates, they also explore and express how morality informs end-of-life care. Arguments for and against medically assisted suicide no longer center just on the ethics of suicide, but, instead, on how much pain a patient should be expected to endure before they look for a way out and how far God's love reaches into the midst of suffering.
Advocates for end-of-life care without the assisted suicide option, such as the Roman Catholic Church, argue that while a terminally ill patient might feel like a financial and emotional burden, he or she remains precious in the eyes of God.
But people of faith who support medically assisted suicide, such as Will Irwin, a retired federal administrative appeals judge and member of the United Church of Christ, believe that God would support providing a way for people in pain to welcome death.
"I have a responsibility to conduct my life in a way that is beneficial … to other people," he said. "I would feel comfortable choosing (medically assisted suicide) when I no longer can. I don't think God's going to blame me for that decision."
The ongoing debate over medically assisted suicide challenges religious groups to revisit the role their faith should play in death and in life, Bregman said, noting that it's leading to broader efforts to bring faith to bear on American health care.
For centuries, people of faith have protected the vulnerable, she added. In today's world, that group includes those with fewer than six months left to live.
In her course on death and dying, Bregman lectures on the many links between religious practice and the rituals surrounding death. She describes the prayers people say around someone's death bed, the predictions believers make about heaven and the spiritual disciplines that are meant to guide people through their final days.
"Religion redirects what you are (supposed) to be concerned about," she said. "Family members and doctors are secondary players. The central drama is between the dying person and God."
Over the past century, the process of dying has been complicated by extreme medical advancements. Developments like defibrillators for the heart and respirators for the lungs lengthen the dying process, leading medical experts to debate the point at which a patient is truly dead, said Ann Neumann, a visiting scholar at The Center for Religion and Media at New York University and author of "The Good Death: An Exploration of Dying in America."
"We've had to ask ourselves, 'How do we define death?'" she said.
As medical revolutions have changed the experience of death, religious groups have had to clarify their end-of-life teachings.
Most major faith groups, including the Catholics, Mormons, Muslims, Jews and Southern Baptists, have published their opposition to medically assisted suicide, arguing that the timing of death is a choice only God can make, according to Pew Research Center. The Church of Jesus Christ of Latter-day Saints teaches that assisted suicide violates God's commandments, but that "members should not feel obligated to extend mortal life by means that are unreasonable."
Most religious leaders say that supporting terminally ill patients means accompanying them through their pain and fear, not allowing them to actively choose death. They also believe that even suffering holds valuable lessons for patients and survivors.
"Some members of religious communities would argue that there is something blessed about having a dying person as part of the group," Bregman said. It's meaningful not just to "be able to care for that person, but also to recognize, in that person's condition, what all of us will face at the end of life."
Faith leaders who do support medically assisted suicide argue that individuals have a right to self-determination in death. The Unitarian Universalist Association has advocated for a patient's right to choose this practice since 1988.
"It is every person's inviolable right to determine in advance the course of action to be taken in the event that there is no reasonable expectation of recovery from extreme physical or mental disability," the 1988 resolution reads.
Irwin's United Church of Christ has yet to formulate a response at the national level, although several regional conferences have passed resolutions supporting medically assisted suicide as an end-of-life option.
Medically assisted suicide
In the four states where medically assisted suicide has been legalized through legislation, regulations are nearly identical. Eligible patients include those who have made two oral and one written request to a physician for life-ending medication after being given less than six months to live. They must also have been deemed psychologically fit to make the decision.
In Montana, medically assisted suicide became an end-of-life option when a judge in the state's first judicial district court ruled that physicians cannot be charged with a crime for providing a lethal dose of medication to a terminally ill, competent patient.
Until 2008, Oregon was the only state where medically assisted suicide was legal. It's quickly gained political traction, due to a growing sense that expanding end-of-life options will reduce the barrage of expensive and often ineffective medical treatments offered to patients clinging to their sense of agency in their final days, as Atul Gawande noted in this 2014 book, "Being Mortal."
Nearly seven-in-10 Americans (68 percent) supported doctor-assisted suicide in 2015, compared to 58 percent a decade early, Gallup reported in May 2015. Fifty-six percent of U.S. adults called the practice "morally acceptable."
However, in other countries that have legalized this option, medically assisted suicide is under increased scrutiny.
A new study on euthanasia in the Netherlands, published this month in JAMA Psychiatry, found that one-in-four psychiatric patients (27 percent) who died with a physician's assistance received the lethal dose of medication from a physician who was new to them. Twenty-four percent involved disagreements among consultants as to whether the procedure was justified. In the Netherlands, unlike in the U.S., people with severe psychiatric problems can request assisted suicide.
Supporters of medically assisted suicide often cite personal experiences when they describe the need for it. Irwin noted that his mother chose to starve herself rather than slowly go blind and suffer from the psychological side effects of the steroids used to treat her arteritis — blood vessel inflammation that affected her optic nerve.
"People ought to have a choice … when they're thinking, 'It's clear it's the end of the road. Let me get off the road,'" he said.
Faith can be as much a part of choosing to die as it is of deciding how to live, Neumann said. The people who take advantage of medically assisted suicide reconcile that choice to their personal religious beliefs, sometimes betraying the official teachings of their faith group in the process.
"I don't think any person who opts to receive a prescription via a legal aid-in-dying (law) sees their behavior as unethical," she said.
More than two-thirds of white mainline Protestants (71 percent) and white Catholics (67 percent) say that a person has a moral right to suicide if he or she is in a great deal of pain with no hope of improvement, according to a 2013 Pew Research Center survey. Around four-in-10 white evangelical Protestants (42 percent) and black Protestants (42 percent) also call medically assisted suicide ethical in this case.
However, far fewer Christians support this end-of-life option when it's chosen because a patient feels like a burden, Pew reported. Only 31 percent of white mainline Protestants, 40 percent of white Catholics, 24 percent of white evangelical Protestants and 21 percent of black Protestants say a patient has a moral right to suicide when he or she is an extremely heavy burden on family members.
Health and human dignity
In addition to arguing that choosing to end one's life is immoral, religious opponents to medically assisted suicide posit that it's a flawed solution to a broken health care system.
The option responds to high medical costs and widespread confusion about end-of-life care by making it easier for vulnerable people to die, couching this upsetting outcome in the language of autonomy, noted Jean Hill, government liaison for the Catholic Diocese of Salt Lake City.
"Choice doesn't exist when you're worried about bankrupting your family," said Hill, who leads conversations about end-of-life care options at Catholic parishes in her area.
However, speaking up about the consequences of enabling doctors and family members to convince a patient who feels like a burden to choose premature death often fails to account for that fact that medically assisted suicide is not the only way to actively welcome death, Bregman noted.
"In a way, we already are tinkering around with the timing" of patients' deaths, she said. Doctors might decide not to treat the pneumonia speeding the death of a terminal cancer patient, or patients could refuse food and water when they're ready to die.
Many faith groups draw a distinction between taking a fatal dose of medication and letting an illness' symptoms lead to natural death.
"Even in traditions that are very much focused on preserving life, there is usually some point at which" medical interventions can and should end, Bregman said.
These faith leaders are working to reclaim the idea of dying with dignity, arguing that choosing to take lethal drugs to reduce a financial or emotional burden on others does not reflect the inherent beauty of all God-given life.
"No life lacks value. No life should be thrown away," Hill said. "To say that physician-assisted suicide would be acceptable at some point would be saying that some lives aren't worth living anymore."
As Bregman witnessed while volunteering at a mental hospital, chaplains and other people of faith believe that a human's value goes beyond economic or social usefulness.
The chaplain's work "was a testimony to (the religious community's) commitment to protect human lives," she said.
In debates over end-of-life decisions, religious groups can affirm the value of all human life, reminding people that their faith community will walk alongside them at all stages of life, Hill said.
"Real compassion is … accompanying people through their fears even before they've gotten a terminal diagnosis. Let's help people understand that they won't be alone, that we won't abandon them," she said.
Religion and death
As Bregman noted, religion has always played a meaningful part in death, teaching believers to hope for a grace-filled afterlife and bringing them comfort through prayers offered around the death bed.
In the modern world, Bregman said, this role should expand to include faith-based activism around a variety of end-of-life issues, like insurance costs, access to advanced treatments and palliative care. She said advocating for or against medically assisted suicide is only one small part of using religious wisdom to address the problems of dying in America.
"Very few people choose (medically assisted suicide) … but it's one of those dramatic cases that leads every faith group to chime in with an opinion," she said.
For the first time, more than 100 people died in 2014 as a result of taking the prescriptions they received through Oregon's Death with Dignity Act, according to data from the Oregon Health Authority. From 1998, when the option became available, to 2007, fewer than 50 Oregonians died each year of medically assisted suicide.
Although Hill is passionate about preventing the practice from being legalized in Utah, she also said that the faith community's commitment to upholding human dignity involves working to bring about systematic changes to the health care system.
"We can advocate for insurance options and medical services that make final moments comfortable," urging policymakers to design health care laws that provide the assistance people need, she said.
When she meets with Catholics in and around Salt Lake City, Hill updates them on the proposed End of Life Options Act, HB264, which went nowhere last year and has yet to receive a hearing in the current legislative session. But she also highlights broader health care policy goals, discussing hospice and other care plans people should consider as they near the end of their life.
"We want people to understand that they have end-of-life care options" that go beyond choosing an early death, she said.
Rep. Rebecca Chavez-Houck, D-Salt Lake, who is sponsoring HB264, agreed that faith communities play an important in helping people discern their end-of-life goals.
"These choices are deeply personal … but faith communities provide solace and support," she said.
Although she's sponsoring an aid-in-dying bill, Rep. Chavez-Houck said she isn't asserting that choosing medically assisted suicide is better than other options. She just believes, like some people of faith, that it deserves to be included in the end-of-life landscape.
"Some individuals feel strongly that self-determination (in death) has been afforded to them by their creator," she said.
In general, faith communities should nurture an environment in which people comfortably discuss death in addition to life, Irwin said.
Next month, he'll help host a conversation on end-of-life care options at his church, during which he's prepared to hear faithful perspectives on medically assisted suicide from both sides of the spectrum.
"The point is getting a conversation going," not making everyone share his viewpoint, he said.
Conversations like these allow people to be better informed, evaluate their own situations and even find hope about the challenging decisions that lie ahead, Irwin added.
"Faith communities care about all of life's important issues — birth, baptism, confirmation, marriage, divorce, loss of a job, illness and death," he said. "If you've been through some of these passages with other people, it is comfortable, and comforting, to ask them for help in thinking about (your) eventual or impending death."
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