The practice of health care providers at all levels brings you into contact with people from a variety of faiths. This calls for basic knowledge and understanding of different

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Physician-Assisted Suicide and Euthanasia: Theological and Ethical Responses

DANIEL P. SULMASY* Georgetown University, Washington, DC, USA

*Address correspondence to: Daniel P. Sulmasy, MD, PhD, MACP, Director, Kennedy Institute of Ethics, Georgetown University, Healy 419, 3700 O St., NW

Washington, DC 20057, USA. E-mail: [email protected].

Euthanasia and rational suicide were acceptable practices in some quarters in antiquity. These practices all but disappeared as Hippocratic, Jewish, Christian, and Muslim beliefs took hold in Europe and the Near East. By the late nineteenth century, however, a political movement to le- galize euthanasia and physician-assisted suicide (PAS) began in Europe and the United States. Initially, the path to legalization was filled with obstacles, especially in the United States. In the last few decades, how- ever, several Western nations have legalized euthanasia, and several US jurisdictions have now legalized PAS, giving state sanction to these once forbidden practices. With increasing social and political pressure to ac- cept PAS, Christians need to understand how to think about this issue from an explicitly Christian perspective. Independent of the question of legalization, there are significant theological and ethical questions. This special issue aims to address those concerns, including: how does the practice of PAS or euthanasia impact our attitudes toward death, and what does it mean to “die well?” Should physicians, as healers, be in- volved in assisting patients who wish to bring about their own death? Are these methods significantly distinguished from other ethically justi- fied practices in end-of-life care that also lead to a person’s death? Can Christians, both as patients and practitioners, justify the use of these methods to relieve suffering in this manner as compatible with the faith? Although these questions are not new to the debate, it is increasingly im- portant that these controversies are addressed as the practice of PAS is popularized.

Keywords: Christianity, euthanasia, physician-assisted suicide

Through a generous grant from the McDonald Agape Foundation, a series of annual conferences convened to examine controversies in Christian thought

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regarding medical care at the end of life. The third of a planned total of five such conferences took place at Georgetown University in November 2018, gathering professionals from a diverse set of backgrounds who drew from both historical and contemporary sources to explore the ethics of physician- assisted suicide (PAS) from a variety of Christian perspectives. This special issue is the fruit of papers initially presented at that conference.

Euthanasia and rational suicide were acceptable practices in some quar- ters in antiquity. These practices all but disappeared as Hippocratic, Jewish, Christian, and Muslim beliefs took hold in Europe and the Near East. By the late nineteenth century, however, a political movement to legalize euthanasia and PAS began in Europe and the United States. Initially, the path to legal- ization was filled with obstacles, especially in the United States. In the last few decades, however, several Western nations have legalized euthanasia, and several US jurisdictions have now legalized PAS, giving state sanction to these once forbidden practices. With increasing social and political pressure to accept PAS, Christians need to understand how to think about this issue from an explicitly Christian perspective.

Independent of the question of legalization, there are significant theolog- ical and ethical questions. This special issue aims to address those concerns, including: how does the practice of PAS or euthanasia impact our attitudes toward death and what it means to “die well?” Should physicians, as healers, be involved in assisting patients who wish to bring about their own death? Are these methods significantly differentiated from other ethically justified practices in end-of-life care that also lead to a person’s death? Can Christians, both as patients and practitioners, justify the use of these methods to re- lieve suffering in this manner as compatible with the faith? Although these questions are not new to the debate, it is increasingly important that these controversies be addressed as the practice of PAS is popularized.

In the first essay of this issue, Lloyd Steffen presents a possible Christian defense of PAS, arguing that, although “a broad Christian perspective would insist on at least a presumptive opposition to assisted suicide .  .  . the central moral issue is whether assisted suicide should be opposed abso- lutely or presumptively” (Steffen, 2021, 230). Rejecting absolutism in ethics, Steffen argues that a “presumptive prohibition” on assisted suicide must also recognize that there are morally complex situations in which what should be done is not clear. Steffen argues for acknowledging that assisted sui- cide is prima facie wrong, while also holding that there might be justifiable exceptions. Appealing to a particular way of thinking about natural law, and making an analogy with just war theory, Steffen defends PAS while remaining committed to Christian values. Ultimately, Steffen argues that the world is a messy place, that moral purity is unobtainable, and that sometimes human beings do things (like developing life-sustaining medical technologies) that lead to unforeseen and problematic consequences. He argues that human beings are responsible for those consequences and are therefore obligated,

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from a moral point of view, to devise ways of being accountable to the duty to respect all persons and their individual freedom––a duty that holds even when they find themselves in unacceptable circumstances and make per- sonal choices with which we might disagree.

Teaming up to offer an account from both medical and philosophical perspectives, Farr Curlin and Chris Tollefsen (2021) challenge the medical profession’s increasing acceptance of so-called “physician aid-in-dying”. They argue that the acceptance of PAS is a symptom of the ascendancy of a “provider-of-services” model for medicine, in which “providers” offer serv- ices to help patients maximize their “well-being” according to the patient’s preferences. They contrast this consumerist model with what they call the Way of Medicine, in which medicine is understood as moral practice oriented to the patient’s health. They note that a refusal intentionally to harm or kill is a touchstone of the Way of Medicine, one unambiguously affirmed by Christians through the centuries. Moreover, physician aid-in-dying contradicts one of the distinctive contributions that the Christian era brought to medi- cine: a taken-for-granted solidarity between medical practitioners and those suffering illness and disability. Insofar as medical practitioners cooperate in aid-in-dying, they turn away from this solidarity and undermine the trust that patients need to be able to have in them when they are sick and debilitated.

My own essay follows, in which I offer a counter-argument to one of many contemporary critiques of opposition to PAS—namely, that there are no rational grounds for making a moral distinction between killing patients through the administration of lethal overdoses and allowing them to die by discontinuing life-sustaining treatments (Sulmasy, 2021). I  res- urrect Augustine’s distinction between martyrdom and suicide to argue that the distinction between killing patients and allowing them to die has the same logical form: it is sometimes permissible to suffer a harm when it is not permissible to inflict a harm. Just as true martyrs accept their in- evitable deaths at the hands of their oppressors but do not provoke their oppressors into killing them, so it is permissible to accept one’s inevitable death from disease but never permissible to bring one’s own death on oneself. The distinction in both cases turns importantly on intention—one cannot make one’s death one’s direct aim, but one can accept a death that is brought on by forces outside one’s control, whether originating in indifferent nature or in sinful human will. I end by suggesting that in forgoing life-sustaining treatments, one may be understood as accepting one’s death as an inevitable biological event, while not submitting to death as a personal event by refusing to make death one’s direct intention. I con- clude that this might constitute a realization of exactly the sort of coinci- dence of opposites that theologians like Karl Rahner (1961) held out as the Christian ideal.

Devan Stahl argues in her essay that Christians have good reason to “faith- fully attend to the concerns of disability advocates” in PAS debates, and that

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“there is a Christian obligation to attend to the voices of persons whose experiences in health care shed light on the pressures vulnerable people feel to end their lives” (Stahl, 2021, 280). She begins her essay with an ac- count of “disability moral psychology,” which elucidates the unique ways persons with disabilities perceive the world, based on their phenomenolog- ical experiences. Stahl then explores the disability critique of PAS, situated in the shared social conditions of persons who are chronically disabled and terminally ill. She argues that “to bear witness to a compassionate God, the- ological and ethical judgments concerning PAS must seek perspectives from persons who claim that their dignity and even their lives are in jeopardy by the practice” (Stahl, 2021, 281). Stahl thereby hopes to teach all Christian ethicists lessons derived from a conversation with the disabled community.

In the last essay in this special issue, Darlene Weaver (2021) argues that situating PAS arguments within the context of the broader “culture wars” obscures an under-acknowledged consensus—both advocates and proponents appeal to respect for persons. This leads her to suggest that a personalist approach to PAS might deepen standard arguments against PAS in a constructive manner that has a prospect of winning over proponents. Christian personalism, in her view, situates PAS within the larger moral obligations of solidarity with the dying and their caregivers. As such, per- sonalism might serve to relocate debates over PAS and allow all parties to harness shared moral impulses. This approach also invites opponents of PAS to engage advocates more charitably and to forge opportunities that allow deeper insights into human existence, suffering, and death.

By refraining from the direct invocation of the more familiar Christian arguments against suicide, such as the idea of life as a gift from God, or the concept of human dignity as the inviolable stamp of the divine image on the human form, these essays enrich the Christian discussion of PAS. They draw deeply from traditional Christian sources, yet explore the question in novel ways. Nonetheless, even Steffen’s idea of a rebuttable presumption against PAS seems dependent on the idea that human life is a great good that cannot be contravened without an incredibly important justification. As Weaver points out, all of the authors believe that Christian charity demands solidarity with the sick and attention to their needs as persons. All acknowl- edge the facts of human suffering and mortality and the need for Christians to accept death as a biological event, just as Jesus did on the cross.

Each of the authors except Steffen, however, would argue that one can never directly intend to make sick, disabled, or terminally ill persons dead, or assist such persons in making themselves dead. Aiming at death contravenes the good of life, undermines the trust that the sick and disabled need to have in the medical profession, and weakens the bonds of social solidarity that Christ taught us constitute His Body. These essays enrich the Christian liter- ature on this perennially important topic, extending the range and depth of

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the human and Christian considerations that ought to inform our choices as we die or care for those who are dying.

ACKNOWLEDGMENTS

Special thanks to MaryKate Gaurke for her superlative assistance in editing this volume and to the McDonald-Agape Foundation for their generous sup- port of this project.

REFERENCES

Curlin, F., and C. Tollefson. 2021. Medicine against suicide: Sustaining solidarity with those diminished by illness and debility. Christian Bioethics 27(3):250–63.

Rahner, K. 1961. On the Theology of Death. New York: Herder and Herder. Stahl, D. 2021. Understanding the voices of disability advocates in PAS debates. Christian

Bioethics 27(3):279–97. Steffen, L. 2021. Physician assistance in dying: An option for Christians? Christian Bioethics

27(3):228–49. Sulmasy, D. P. 2021. Killing and allowing to die: Insights from St. Augustine. Christian Bioethics

27(3):264–78. Weaver, D. 2021. The case against physician-assisted suicide: A personalist approach. Christian

Bioethics 27(3):298–311.

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© 2021 The Journal of Christian Bioethics Inc. Copyright of Christian Bioethics: Non- ecumenical Studies in Medical Morality is the property of Oxford University Press / USA and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

BACKGROUNDER

Key Points

Always Care, Never Kill: How Physician-Assisted Suicide Endangers the Weak, Corrupts Medicine, Compromises the Family, and Violates Human Dignity and Equality Ryan T. Anderson, PhD

No. 3004 | March 24, 2015

n Doctors may help their patients to die a dignified death from natural causes, but they should not kill their patients or help them to kill themselves. This is the reality behind euphemisms such as “death with dignity” and “aid in dying.”

n Physician-assisted suicide (PAS) endangers the weak and mar- ginalized in society. Where it has been allowed, safeguards pur- porting to minimize this risk have proved inadequate.

n PAS corrupts the profession of medicine by permitting the tools of healing to be used as tech- niques for killing, it distorts the doctor–patient relationship, and it provides perverse incentives for insurance providers.

n PAS undermines social solidarity, increasing the temptation to view elderly or disabled family mem- bers as burdens and the tempta- tion for those family members to view themselves as burdens.

n PAS violates equality before the law by judging some to have lives no longer “worth living.”

n We should respond to suffering with appropriate medical care and human presence.

Abstract Allowing physician-assisted suicide would be a grave mistake for four reasons. First, it would endanger the weak and vulnerable. Second, it would corrupt the practice of medicine and the doctor–patient rela- tionship. Third, it would compromise the family and intergenerational commitments. And fourth, it would betray human dignity and equality before the law. Instead of helping people to kill themselves, we should offer them appropriate medical care and human presence. We should respond to suffering with true compassion and solidarity. Doctors should help their patients to die a dignified death of natural causes, not assist in killing. Physicians are always to care, never to kill.

The hippocratic Oath proclaims: “I will keep [the sick] from harm and injustice. I will neither give a deadly drug to anybody who

asked for it, nor will I make a suggestion to this effect.”1 This is an essential precept for a flourishing civil society. No one, especially a doctor, should be permitted to kill intentionally, or assist in killing intentionally, an innocent neighbor.

human life need not be extended by every medical means pos- sible, but a person should never be intentionally killed. Doctors may help their patients to die a dignified death from natural causes, but they should not kill their patients or help them to kill themselves. This is the reality that such euphemisms as “death with dignity” and “aid in dying” seek to conceal.

In 2015, at least 18 state legislatures and the District of columbia are considering whether to allow physician-assisted suicide (PaS).2 Legalizing physician-assisted suicide, however, would be a grave mistake because it would:

This paper, in its entirety, can be found at http://report.heritage.org/bg3004

The Heritage Foundation 214 Massachusetts Avenue, NE Washington, DC 20002 (202) 546-4400 | heritage.org

Nothing written here is to be construed as necessarily reflecting the views of The Heritage Foundation or as an attempt to aid or hinder the passage of any bill before Congress.

2

BACKGROUNDER | NO. 3004 March 24, 2015

n Endanger the weak and vulnerable,

n corrupt the practice of medicine and the doctor– patient relationship,

n compromise the family and intergenerational commitments, and

n Betray human dignity and equality before the law.

First, PaS endangers the weak and marginalized in society. Where it has been allowed, safeguards purporting to minimize this risk have proved to be inadequate and have often been watered down or eliminated over time. People who deserve society’s assistance are instead offered accelerated death.

Second, PaS changes the culture in which medicine is practiced. It corrupts the profession of medicine by permitting the tools of healing to be used as tech- niques for killing. By the same token, PaS threatens to fundamentally distort the doctor–patient relation- ship because it reduces patients’ trust of doctors and doctors’ undivided commitment to the life and health of their patients. Moreover, the option of PaS would provide perverse incentives for insurance providers and the public and private financing of health care. Physician-assisted suicide offers a cheap, quick fix in a world of increasingly scarce health care resources.

Third, PaS would harm our entire culture, espe- cially our family and intergenerational obligations. The temptation to view elderly or disabled family members as burdens will increase, as will the temp- tation for those family members to internalize this attitude and view themselves as burdens. Physician- assisted suicide undermines social solidarity and true compassion.

Fourth, PaS’s most profound injustice is that it violates human dignity and denies equality before the law. Every human being has intrinsic dignity and immeasurable worth. For our legal system to be coherent and just, the law must respect this dig- nity in everyone. It does so by taking all reasonable steps to prevent the innocent, of any age or condition,

from being devalued and killed. classifying a sub- group of people as legally eligible to be killed violates our nation’s commitment to equality before the law— showing profound disrespect for and callousness to those who will be judged to have lives no longer

“worth living,” not least the frail elderly, the dement- ed, and the disabled. No natural right to PaS exists, and arguments for such a right are incoherent: a legal system that allows assisted suicide abandons the natural right to life of all its citizens.

Doctors should help their patients to die a dignified death of natural causes, not assist in killing. Physicians are always to care, never to kill.

Instead of embracing PaS, we should respond to suffering with true compassion and solidarity. People seeking PaS typically suffer from depression or other mental illnesses, as well as simply from loneliness. Instead of helping them to kill themselves, we should offer them appropriate medical care and human pres- ence. For those in physical pain, pain management and other palliative medicine can manage their symptoms effectively. For those for whom death is imminent, hospice care and fellowship can accompany them in their last days. anything less falls short of what human dignity requires. The real challenge facing society is to make quality end-of-life care available to all.

Doctors should help their patients to die a dig- nified death of natural causes, not assist in killing. Physicians are always to care, never to kill. They properly seek to alleviate suffering, and it is reason- able to withhold or withdraw medical interventions that are not worthwhile. however, to judge that a patient’s life is not worthwhile and deliberately has- ten his or her end is another thing altogether.

citizens and policymakers need to resist the push by pressure groups, academic elites, and the media to sanction PaS. recent experience with PaS both in

1. Ludwig Edelstein, The Hippocratic Oath: Text, Translation and Interpretation (Baltimore, MD: Johns Hopkins University Press, 1943), http://guides.library.jhu.edu/content.php?pid=23699&sid=190555 (accessed January 28, 2015).

2. State legislation as of March 20, 2015: Alaska, HB 99; California, SB

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