In contemporary usage, the term euthanasia does not simply mean the quest of palliative medicine to relieve pain, but the act of deliberately killing someone in order to end suffering for “merciful reasons”. Appeal is made to the superior interest of the State for ulterior “justification” of such acts, since, it is claimed, that the State has sovereign power over the bodies of those of its members who have become useless to society.

Assisted suicide is a specific form of euthanasia which is spreading in contemporary society. Pope John Paul II devotes three articles of the encyclical Evangelium Vitae (nn. 65-67) to the subject. A mentality closed to the possibility of the transcendent easily succumbs to the illusion of painless death. Only in the transcendent, i.e. in openness to God the Creator, can existence find its full meaning. It is only in Christ that all phases of life, and all forms of suffering and death, accepted in trusting obedience, acquire a value beyond the capacities of creatures. (Bioethics Committees; Informed Consent; A New Paradigm of Health Care; Quality of Life; Sexual and Reproductive Health)

Forward

In its etymology, the term euthanasia (from the Greek eu, good; thanatos, death) means a serene natural death which happens without particular suffering or anxiety, bitterness or regret, and at peace with oneself, God and one’s neighbor. In the modern era, F. Bacon speaks of euthanasia in terms of “the relief of suffering, even when such assists in procuring a peaceful and tranquil death” (Novum Organum). F. Nietzsche sings the praises of “a liberated death coming to me because I have willed it” (Thus Spake Zarathustra).

The main problem with the current debate on euthanasia is found in the general, and almost obstinate, ambiguity in the use of this term. Indeed, the word “euthanasia” is currently and indiscriminately employed to designate both the decision to anticipate the end of the life of someone rendered apparently incurable by illness or old age, and palliative medicine in its struggle against pain; as well as the legitimate voluntary decision to decline unnecessary disproportionate treatments or those which pose higher than acceptable risk (refusal of burdensome medical treatment).

Euthanasia must be properly understood as the deliberate act of killing an incurable patient so as to end his suffering, motivated by pity. Posed in these terms, all the ambiguity of this concept becomes evident. On the one hand, we have a technical formulation - deliberate or direct killing (it is irrelevant whether provoked by a positive act or by an omission- which excludes any equation with the various forms of involuntary homicide (unintentional, culpable etc.). On the other hand, there is a concern to justify such homicide by the introduction of the sentiment of pity, which, nevertheless, remains a strange pity from the moment it leads to the killing of a suffering person, with or without that person’s prior consent (voluntary or involuntary euthanasia).

Euthanasia in the context of contemporary culture

Death has a dual and opposite meaning in any culture which refuses to address questions about the meaning of life and systematically excludes any consciousness of mortality: death becomes an unacceptable paradox, especially when it unexpectedly truncates an existence with a very promising future; or else death is seen as a liberation from a meaningless existence, sometimes irreversibly submerged in anguish and suffering. Having lost sight of the meaning of suffering, only desperation remains, giving rise to the temptation to end the pain of living as painlessly as possible.

While a mentality closed to the transcendent can succumb to the illusion of an easy death, at the same time, contemporary culture does not lack defense mechanisms, deeply rooted in common sense, which operate effectively against the temptation of euthanasia. Let us examine those concrete mechanisms:

1. A revulsion at the idea that a doctor could have an active and deliberate role in the death of any patient. This inherited attitude derives from the Hippocratic tradition. A doctor is someone to whom we entrust ourselves precisely when illness and suffering threaten our spiritual and physical powers and endanger life. A doctor is not asked to judge or determine who should live and who should die; the trust the patient gives is based on the presupposition of professionalism and the unchanging pro vita attitude of the doctor. If both these elements were to be found generally lacking, the damage to the doctor-patient relationship would be incalculable. Clearly, this is a very serious issue, and hence, in recent years, the International Medical Association has twice issued statements categorically opposed to all forms of euthanasia, including that adopted in Holland [1].

2. Fear of abuses or the slippery slope with no possible escape. Everyone experiences dismay and compassion when confronted with the desire to die expressed by someone like us. Indeed, we can even go so far as to understand the reasons motivating such a decision. But indulgence cannot cause us to overlook serious considerations such as the fear of having misunderstood someone’s wishes, or the possibility that one was dealing with a mentally sick person, or the risk of causing irreparable damage etc. Such considerations are too realistic to allow us to think that we are authorized to satisfy a person’s desire to die. It must also be stated that abuses are not as remote a possibility as some might think. One only has to think of the program devised by Professors K. Binding and A. Hoche for the annihilation of those lives deemed unworthy of living [2] and applied without limits by the Nazi regime, or the proposals made a number of years ago by Dr. Brody for assisted suicide [3], or even the not infrequent cases that appear from time to time in the mass media.

3. Religious convictions. The ideas derived from religious convictions with regard to man’s origin and destiny cause anxiety among believers not only with regard to the abuses that can arise in relation to painless death. The entry into and departure from this world of the sons of Adam are far too decisive and mysterious events to admit of the intrusion of any human authority. Nobody chooses to be born and nobody can escape death. The religious believer accepts with a sense of security and consolation the belief that only the God of life has dominion over death.

In recent years, the controversy surrounding euthanasia arose from the traditional scenario of an incident of dramatic unbearable suffering followed by a gesture of unlikely compassion. Today it is presented as a choice (death by choice) which has to be recognized, or as an expression of pluralism, or as a solution demanded by changes in health care, or as something which is required out of respect for a patient’s autonomous wish to die rather than to live. Let us examine each of these arguments.

1. The socio-legal factor. While legislation in favor of euthanasia may still seem far off, it must be recognized that it is no longer an impossibility - - as is clear from the legislative developments in several western countries, and from a number of opinion polls conducted among the general public and in the medical profession. This situation tends to make debate on the subject of euthanasia more concrete and encourages both sides to concentrate on arguments easily accessible to the general public while overlooking more fundamental issues of the principles of natural anthropology and doctrine. The argument from pluralism is fallacious because, while society does and ought to admit a plurality of convictions and beliefs, it cannot admit a plurality of laws. There can be only one legal order which is the same for all. Legalizing euthanasia would imply not only removing penal sanctions, but above all would also predispose the structures and procedures of the health care system to make it more easily accessible and safe to all. As in the case of abortion, a tolerant law would offer a permissive solution, which in turn would create incentives for an inhuman practice at the expense of other more ethically acceptable and just solutions.

2. The socio-medical factor. As has already been noted, in society, the medical doctor automatically discharges a service to life. This is the spirit of the Hippocratic Oath and this continues to be the code of medical ethics sanctioned by Geneva. At the same time, however, certain currents are to be found that seek to modify the professional status of the medical doctor so that he would become a decisive instrument in containing budgetary spending on health care, and in instituting a policy of selection based on the quality of life concept. The crisis of the welfare state, shrinking resources with the consequent need to reduce health care spending, according to some, should convince doctors to exclude certain categories of persons –primarily the old–from the most expensive treatments. Thus, certain procedures, that have many points in common with euthanasia, enter into hospital practice by the back door. Similarly, others advance the idea that since modern medicine is responsible for the survival of a growing number of handicapped persons or of persons with a low quality of life (the aged, chronically ill etc.), it should assume responsibility for a burden that is becoming increasingly unbearable for society by deploying adequate measures–such as suspension of treatment, artificial feeding and hydration, and involuntary euthanasia etc.

3. With regard to the question of individual freedom, note must be taken of the well known weight that the so-called pro choice argument has had in the legalization of abortion, especially in the United States. Applied to euthanasia, this argument, however, is less effective, since it is relatively easy to support a woman’s choice to reject a tiny embryo bereft of all possibility of defending its own rights, and not at all clear why a patient’s will to die ought to prevail over the professional competence of a medical doctor who can apply effective palliative treatment. For this reason, proponents of euthanasia are aware of the necessity of changing the role of the medical doctor in such a way that the lethal proposal comes not from him, but from the patient. Hence, we arrive at the notion of suicide. And thus, the traditional but ambiguous notion of mercy killing begins to cede ground to the more rational and insidious one of “assisted suicide”.

As a concept, assisted suicide is a half-way house between suicide and voluntary euthanasia both of which presuppose a clear will to die on the part of a particular subject. Assisted suicide shares with simple suicide the fact that the person ends their own life; while in voluntary euthanasia, death comes about in the context of a painful or incurable illness (or in conditions held to be analogous such as old age) and by the intervention of a medical doctor. Assisted suicide is characterized by the following particular traits: a) death appears as a choice of the patient who, having been informed of his irreversible pathological condition, prefers not only to decline therapy that is no longer effective but also to accelerate the arrival of an inevitable death; b) the medical doctor’s role should be limited to supplying the means by which the patient kills himself (together with the necessary instructions) and to ensuring that death is brought about safely and painlessly; c) the motivation that renders the medical doctor’s intervention legitimate and a duty is no longer a passing feeling, such as pity, but a strict obligation to respect the patient’s will and autonomy.

Assisted suicide has a triple advantage over traditional euthanasia as far as modern sensibilities are concerned. They are: a) the lethal action appears as the patient’s free choice; b) the presence of a medical doctor guarantees professional assistance; but c) above all else, ending life is moved to a less demanding ethical plane, similar to refusing useless treatment.

The problem of the incompetent patient, who cannot express their wishes and is even less capable of killing himself, remains unresolved. A procedure of euthanasia that would exclude such patients is not even considered today. Promoters of euthanasia look to living wills as the best means of circumventing this obstacle. This is a document in which the subject leaves precise instructions about how he wishes to be treated should he become critically or terminally ill.

The concept of assisted suicide leaves many unanswered questions. It is not credible, as in the case of abortion, that any eventual legalization of euthanasia will only be used by those who freely wish to avail of it. All citizens would be exposed to the risk of being “killed by suicide.” How and who can distinguish between a genuinely free decision and one made in depression, pain, dejection etc.? Who can determine the true wishes of an incompetent patient? How can we ensure that assisted suicide does not become a cover for a cunning form of involuntary euthanasia designed to eliminate the handicapped? How is a medical doctor to act when a patient is no longer able to administer a lethal substance to himself or when a patient bungles its administration? Again, were euthanasia to become an alternative “therapy” for terminally ill patients, why should not a medical doctor consider himself authorized to use it in extreme cases without reference to the patient’s will?

The principle official document of the Catholic Church on euthanasia is the declaration Iura et Bona, published by the Congregation for the Doctrine of the Faith in 1980. It is a short compendium of Catholic moral principles dealing with illness and death. In reply to particular questions raised by medical doctors, Pius XII condemned the Nazi practice of euthanasia. The 1980 declaration not only repeated previous teaching but also demonstrated an awareness of the evolving situation with regard to euthanasia and new life-saving therapies [4]. To this document must be added the particularly solemn words of condemnation of euthanasia contained in the encyclical letter Evangelium vitae. John Paul II declares: “in harmony with the Magisterium of my Predecessors and in communion with the Bishops of the Catholic Church, I confirm that euthanasia is a grave violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person” [5].

As a decisive ethical argument, the declaration Iura et Bona, confirming the unanimous previous teaching of the Church, points to the principle of the inviolability of human life, thereby contesting in the most definitive manner the two anthropological postulates underlying both voluntary euthanasia and assisted suicide: on the one hand the postulate that, in some circumstances, death would be a good and life an evil; and on the other, the postulate that man has a right arbitrarily to procure his own death or to cause the death of others. The document denies that pain is an absolute evil to be avoided at all costs: while it is an obligation in charity to do everything possible to alleviate the suffering of the sick, one cannot overlook the positive significance of suffering freely accepted and sustained by faith in Christ.

Pity and beneficence can be expressed in myriad ways, as for example in the parable of the Good Samaritan. Killing a terribly suffering brother, however, has no place among them. Catholic teaching proclaims that life is a marvelous gift and a task entrusted to man by God. Precisely because it is a gift and a mission received from the Lord, life must be administered and lived to the full, always trusting in the designs of God’s divine love, especially in times of trouble. The Christian vision of life and death reaches its climax and true significance in striving for the fulfillment of the promise of new life in the risen Christ. Catholic morality, therefore, regards euthanasia and assisted suicide as evils which are contrary not only to abstract dogmatic principles, but also to the good which is man’s proper end, because they contradict his most intimate nature and his vocation to happiness. Christians believe that as well as receiving life from their parents, the Lord has given them Life which, in St. John’s Gospel, means the life which the Father, in Christ, gives to those who believe. That Life will be completely revealed at the end of time. Personal conviction of the immorality of euthanasia is not sufficient. As John Paul II says, in the context of contemporary society and culture: “the duty of the Christian community is wider than simply condemning euthanasia, or of obstructing its diffusion and legalization. The more basic question is above all that of succeeding in helping the people of our times to come to a realization of the inhumanity of certain aspects of the dominant [contemporary] culture and to rediscover the more important values which it obfuscates” [6].

When one becomes ill, trusting in divine providence, neither removes the personal obligation to treat oneself or have oneself treated, nor imposes the obligation to seek every available remedy. Iura et Bona states that “it will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources”m [7].

To facilitate a prudential application of these general principles, the declaration adds the following clarifications:

1. In the absence of other remedies, with the patient’s permission, it is licit to have recourse to therapies developed by the most recent medical research even when such are still at an experimental stage and not exempt from some degree of risk;

2. It is also licit to interrupt the application of such therapies should their results not prove as successful as had been hoped;

3. It is always licit to be satisfied with normal therapies available to medical practice;

4. In the case of imminent and inevitable death, it is licit in conscience to decline treatments that can only painfully and precariously prolong life, without however withdrawing normal care due to the sick in similar cases [8].

Christianity, in its opposition to the pro-euthanasia culture, exposes the contradictions and the weakness of an ideology that is incapable of appreciating the drama experienced by a patient, sometimes totally isolated from everyone else, who can no longer bear to live. The desire to die is not infrequently the result of inhuman and unjust situations, or of pathological conditions often overlooked or even ignored. It cannot be denied that prolonged and unbearable suffering, and other psychological conditions, can obscure the patient’s mind, even to the point of believing that one may legitimately, and in good faith, ask to die or procure death for others. The resultant suicide or homicide can be unimputable because of an impaired or erroneous judgment of conscience. Killing an unfortunate patient, however, is inadmissible. The Church is insistent on this point when she recalls that “the pleas of gravely ill people who sometimes ask for death are not to be understood as implying a true desire for euthanasia; in fact, it is almost always a case of an anguished plea for help and love. What a sick person needs, besides medical care, is love, the human and supernatural warmth with which the sick person can and ought to be surrounded by all those close to him or her, parents and children, doctors and nurses” [9].

It is with difficulty, moreover, that a request for euthanasia can be regarded as deriving from a truly free choice. The patient in such circumstances only experiences despair and solitude and has no experience of death. Death can only be imagined: it cannot be measured or described. It is the only human event that excludes all possibility of turning back. Paradoxically, there is no other moment in life in which it is more fundamental to revive hope as when one is near death: death is the moment in which all of life comes to full meaning, but only if it remains open to the possibility of a future.

As Evangelium vitae explains, “the certainty of future immortality and hope in the promised resurrection cast new light on the mystery of suffering and death, and fill the believer with an extraordinary capacity to trust fully in the plan of God. The Apostle Paul expressed this newness in terms of belonging completely to the Lord who embraces every human condition: “None of us lives to himself, and none of us dies to himself. If we live, we live to the Lord, and if we die, we die to the Lord; so then, whether we live or whether we die, we are the Lord’s” (Rom 14:7-8). Dying to the Lord means experiencing one’s death as the supreme act of obedience to the Father (cf. Phil 2:8), being ready to meet death at the “hour” willed and chosen by him (cf. Jn 13:1), which can only mean when one’s earthly pilgrimage is completed. Living to the Lord also means recognizing that suffering, while still an evil and a trial in itself, can always become a source of good. It becomes such if it is experienced for love and with love through sharing, by God’s gracious gift and one’s own personal and free choice, in the suffering of Christ Crucified. In this way, the person who lives his suffering in the Lord grows more fully conformed to him (cf. Phil 3:10; 1 Pet 2:21) and more closely associated with his redemptive work on behalf of the Church and humanity” [10].