SEMINAR ON HUMAN DIGNITY AND ETHICAL CHALLENGES IN THE BEGINNING AND END STAGES OF HUMAN LIFE (SANTA SOPHIA CATHOLIC CHURCH, SAN DIEGO DIOCESE, CA, 23, 2012) FR. CHUKWUEKWU SYLVESTER NWUTU PART TWO: DYING WITH DIGNITY AND IN CHRISTIAN SERENITY 1. INTRODUCTION In modern bioethics, nothing is, in itself, either valuable or inviolable, except utility. 1 Stark utilitarianism, represented in the thoughts of Joseph Fletcher, Peter Singer, etc., is the product of this bioethics that devalues some human lives and views people at the margins, such as the pre natally unwell, prematurely born, the disabled and despairing, materially poor, elderly, patients in permanent vegetative state, patients with chronic illnesses, the dying, etc., as expendable. This mentality is at the root of what, Pope John Paul II, called in his Encyclical Evangelium Vitae, a culture of death, which is founded on hedonism and sustained by an exaggerated and false understanding of individual autonomy, understood as the power for an individual to do whatever he likes with his life as a personal possession. 2 Catholic Christian Anthropology, on the other hand, recognizes and defends the intrinsic dignity and inalienable rights of all human beings, founded not on what they have or what they can do, but on the fundamental fact of their being humans, made in the image and likeness of God (Cf. Gen 1:26 27). The sacredness of all human lives and the obligation to protect 1 See Wesley J. Smith, Culture of Death: The Assault on Medical Ethics in America, San Francisco, California: Encounter Books, p.10 2 Cf., John Paul II, Evangelium Vitae, nos. 20 and 23
and promote the good of all human lives from conception to natural death is premised on this similitude with the creator. John Paul II rightly reiterated the responsibility of scientific progress and the dignity of the medical profession, to participants at an international congress on life sustaining treatments and vegetative state: I exhort you to guard jealously the principle according to which the true task of medicine is to cure if possible, always to care. As a pledge and support of this, your authentic humanitarian mission to give comfort and support to your suffering brothers and sisters, I remind you of the words of Jesus: Amen, I say to you, whatever you did for one of these least brothers of mine, you did for me (Mt 25:40). 3 This view is also re iterated by the United States Conference of Catholic Bishops (USCCB) in the Ethical and Religious Directive for Catholic Health Care Services to underscore the Catholic vision of End of Life Care. 4 7. THE SICK AND THE DYING VIS A VIS THE SOLUTIONS OF EUTHANASIA AND ASSISTED SUICIDE 7.1 What is Euthanasia? The 1980 Vatican Declaration on Euthanasia defines euthanasia as an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated. Euthanasia s terms of reference, then, are to be found in the intention of the will and of the methods used 5. Etymologically, the term euthanasia derives from the combination of two Greek words: eu (good or well) and thanasia (death), and was commonly used to 3 John Paul II, Address to the Participants in the International Congress on Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas, March 20, 2004, accessed in www.vatican.va 4 USCCB, ERD, Part Five, Introduction, pp. 29-30 5 Sacred Congregation for the Doctrine of Faith (CDF), Declaration on Euthanasia, 1980, Part II
describe a good or happy death. 6 However, the CDF definition makes clear that euthanasia has more appropriately acquired the meaning of mercy killing embraced as remedy for eliminating grave suffering due to illness and all forms of abnormalities and disabilities. Proponents of voluntary euthanasia appeal chiefly to the principle of individual autonomy and the moral obligation to respect personal choice. Like birth control, death control, they would argue is an expression of individual personal dignity. In addition, from the moral point of view, both active euthanasia, which is the result of an act of commission, and passive euthanasia, which is caused by an act of omission are the same. Both constitute the intentional destruction of the life of an individual for reasons of mercy, because that life is now considered useless and burdensome from sickness, disability and suffering. This is different from the responsible choice to withhold or withdraw medical treatments that become excessively burdensome and matter of factly useless in the context of the patient s overall wellbeing and recovery. 7 7.2 What is Physician Assisted Suicide? Dr. Timothy E. Quill, one of the champions of physician assisted suicide has accurately defined it as the act of making a means of suicide available to a patient who is otherwise physically capable of suicide, and who subsequently acts on his or her own. It is distinguished from voluntary euthanasia, where the physician not only makes the means available but is the actual agent of death 6 William May, Catholic Bioethics and the Gift of Human Life, Huntington, Indiana: Our Sunday Visitor, 2008, p. 262 7 Cf., William May, Op Cit., p.263
upon the patient s request. 8 Therefore, the major difference between euthanasia and physician assisted suicide is that, whereas a person other than the one killed is the principal cause of death in euthanasia, in assisted suicide the person killed is himself or herself the principal cause of death, while the physician or any other person who formally cooperates in the process of bringing about death is an instrumental cause. Given that it is the physician who normally provides this assistance it is common to find this process described as physicianassisted suicide. Generally, the same moral and juridical questions are associated with both euthanasia and physician assisted suicide. 7.3 Ethical Evaluation of Euthanasia and Assisted Suicide 7.3.1 Autonomy and Quality of Life Judgments A fundamental platform for arguments in support of euthanasia resides in the principle of autonomy understood wrongly as an unlimited and unrestrained power by which an individual gives direction to his life, which is seen and treated as a personal possession. As William May has rightly observed, autonomy in this context implies the right to death control, that is, the freedom of selfdetermination in choosing to be killed when one determines that his life has become useless, and determines also the duty of others to respect this choice to be mercifully killed rather than bear the indignity of a life that is burdensome and no longer worth living. Therefore, being able to control one s own life and determining the manner of one s demise, is an expression of human autonomy and dignity. 9 8 Timothy E. Quill, Death and Dignity, in Last Rights: Assisted Suicide and Euthanasia Debated, ed. Michael M. Ulhmann, Washington, DC/Grand Rapids, MI: Ethics and Public Policy Center/William B. Eerdmans Publishing Co., 1998, pp. 327-328 9 Cf., William May, Op Cit., pp. 264-265
Secondly, the quality of life judgments made in respect of those killed through euthanasia is premised on the false assumption that there they are either not yet persons (like the unborn and some infants) or are no longer persons (like patients in coma or permanent vegetative states, PVS). Such lives, devoid of the personhood criteria of exercisable cognitive functions and a complete lack of interest and the ability to feel pleasure, become excessively burdensome and useless, proponents would argue, that such human beings are better dead than alive. Here abortion, especially of the unborn with congenital diseases, infanticide of handicapped newborns, and euthanasia of individuals in extreme situations of illnesses, are strongly recommended and embraced as responsible and acceptable means of dealing with otherwise painful and burdensome situations. 7.3.2 A Critique of a False Notion of Autonomy Autonomy as a fundamental value of human life implies a recognition of the value of human existence. Autonomy, expressed in self determining choices cannot be exercised in a vacuum; it has its proper context. In other words, the value of autonomy is derivative from and reflective of, that which gives value to our humanity. So it should be clear that the claims of autonomy cannot properly extend to choices, which are inconsistent with recognizing the basic worth and dignity of every human being. 10 Now, being a human value, autonomy, understood as self determination is not unlimited, and its goal is to aid the attainment of man s true happiness and ultimate fulfillment. John Paul II has rightly observed: it is through his acts that man attains perfection as man, as one who is called to seek his Creator of his own accord and freely to arrive at full and 10 Luke Gormally, ed., Euthanasia, Clinical Practice and the Law, London: The Linacre Center for Health Care Ethics, 1994, pp. 131, 132
blessed perfection by cleaving to him. 11 In freedom man determines his moral identity in and through the choices he makes for or against the Good, for or against the Truth, and ultimately for or against God. 12 Now the principal good of the human person is the good of human life, from the first moment of conception to natural death, because it is the good on which all the other human goods are founded. According to the CDF declaration on euthanasia: No one can make an attempt on the life of an innocent person without opposing God's love for that person, without violating a fundamental right, and therefore without committing a crime of the utmost gravity. 13 John Paul II further observes that human freedom is exercised rightly and in a manner that guarantees human fulfillment or perfection only when it is guided by the truth. And we discover this truth ultimately in God s wise and loving plan for human life and existence. The CDF is therefore right to posit that: intentionally causing one's own death, or suicide, is therefore equally as wrong as murder; such an action on the part of a person is to be considered as a rejection of God's sovereignty and loving plan. The USCCB has also rightly affirmed: The truth that life is a precious gift from God has profound implications for the question of stewardship over human life. We are not the owners of our lives and, hence, do not have absolute power over life. 14 Similarly, William May has seminally argued: if our choices seriously undermine in us our capacity to flourish as human person, and if, a fortiori, they aim to damage aspects of this capacity in others, there is no reason to respect 11 John Paul II, Encyclical Letter, Veritatis Splendour, no. 71 12 Ibid, no. 65 13 CDF Declaration on Euthanasia, Part II 14 USCCB, ERD, Part Five, Introduction, PP. 29-30
such choices. And the intentional killing of ourselves or others, no matter what the reason, is a choice that sets us against the inherent goodness of human life. 15 Finally, as the CDF has forthrightly stated, one must clearly distinguish suicide from that sacrifice of one's life whereby for a higher cause, such as God's glory, the salvation of souls or the service of one's brethren, a person offers his or her own life or puts it in danger (cf. Jn. 15:14). 16 8. THE ETHICS OF BENEMORTASIA From the Latin, bene (good) and mortasia (death), this term means a happy or good death, and is credited to Arthur Dyck, to express the human person s right to die, not by forcing and procuring death, but naturally and peacefully in human and Christian dignity. 17 A similar term, agathanasia from the Greek agathos (good) and thanasia (death), was coined by late Paul Ramsey, a great advocate of the culture of life ethics to express the same truth. 18 This truth is predicated on a vision that welcomes life as an intrinsic good and affirms that it is always wrong, and utterly incompatible with the love for God and neighbor to intentionally kill innocent human life. It is a vision that sees a vicarious meaning in human suffering and requires that in caring for the sick and dying, one is always to make use of ordinary and proportionate means of preserving and promoting life, but one is free to withhold or withdraw extraordinary or disproportionate means of doing so. 19 According to Christian teaching, however, suffering, especially suffering during the last moments of life, has a special place 15 Cf. William May, Op. Cit., p.272 16 CDF, Declaration on Euthanasia, Part II 17 CDF, Op. Cit, Part IV 18 Paul Ramsey, On (Only) Caring for the Dying in Patient as Person, New Haven: Yale University Press, 1970, pp. 113-164 19 William May, Op. Cit., pp.275-276
in God's saving plan; it is in fact a sharing in Christ's passion and a union with the redeeming sacrifice which He offered in obedience to the Father's will. 20 Ultimately, this vision considers and welcomes natural death as unavoidable and a necessary process of human existence, which is critical to our full realization as made in the image of God, that is, our hope of seeing God face to face in an undying life. 8.1 Proportionate and Disproportionate Means of Care Basically, proportionate (ordinary) means are those treatments that respect the dignity of the sick person, are effective in offering a reasonable hope of benefit to the patient, do not carry excessive burden or impose excessive expense, and are morally required. Disproportionate (extraordinary) means are interventions that are unduly burdensome, ineffective, impose excessive expense, and are therefore not morally required. 21 Pope Pius XII in his address to a congress of anesthesiologists in 1957 makes a valuable contribution on this subject. According to the Pontiff: normally one is held to use only ordinary means (to prolong life) according to the circumstances of persons, places, times, and culture that is to say, means that do not involve any grave burden for oneself or another. A stricter obligation would be too burdensome for most men and would render the attainment of the higher, more important good too difficult. Life, health, all temporal activities are in fact subordinated to spiritual ends. On the other hand, one is not forbidden to take more than the strictly necessary steps to preserve life and health, so long as 20 CDF, Op. Cit., Part III 21 Cf., USCCB, ERD, nos. 56 and 57, p.31; Moira McQueen, Bioethics Matters, A Guide for Concerned Catholics, London: Burns and Oates, 2009, p.80
he does not fail in some more important duty. 22 With regard to the means relevant in any particular situation, a correct judgment call is made, according to the CDF declaration on euthanasia: 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. 23 8.2 Nutrition and Hydration for Patients in Vegetative State Questions have been raised regarding the appropriateness of providing nutrition and hydration to patients for whom all available medical treatments have become both useless and burdensome. The Church has consistently taught that we are obliged to always assure the basic care to the sick and the dying, including those whose death is irreversible and imminent and patients in persistent vegetative state. Such care includes the basic necessities of life like food, water, air, rest and warmth. In the words of John Paul II: I should like particularly to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering. 24 In the 2222 Pope Pius XII, The Prolongation of Life: An Address to an International Congress of Anaesthesiologists, as reprinted in Death, Dying, and Euthanasia, p.284 23 CDF Declaration of Euthanasia, Part IV 24 John Paul II, Address to the Participants in the International Congress on Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas, March 20, 2004, accessed in www.vatican.va
same vein the USSCB makes the following provision: In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching. 25 8.3 Advanced Directives Basically, an advance directive is a document by which an individual provides for decisions that should be made regarding his health in an event he becomes incapable of making such decisions in the future. There are two main types, namely: the living will, and the durable power of attorney. 26 The living will is a signed, witnessed or notarized document by which a person directs that certain life sustaining treatments be either withheld or withdrawn if such an individual is in a terminal condition and unable to make healthcare decisions. One major downside to this is that frequently, the attending physician who has to carry out such directives may be unfamiliar with the patient s values and wishes ordinarily, and because the language used is often vague and too open ended, it could become difficult to distinguish a suicidal intention (refusing treatment as a way of ending one s life), and non suicidal intention (forgoing treatment because such treatment has become useless and will only lead to a burdensome prolongation of life). 27 The Durable Power of Attorney, also a signed, witnessed or notarized document, is a much preferred provision, because here an agent or agents, who are generally conversant and largely share the signer s values and wishes, are the ones empowered to make healthcare decisions for the latter when he becomes 25 USCCB, ERD, nos. 58 and 59, p.31 26 William May, Op. Cit., p.302 27 Ibid., pp.302-303
incapable of doing so. A Catholic, for instance, is expected to choose Catholics who, like himself or herself, know and accept and promote the Church s teaching on the sacredness and inviolability of innocent human life from the moment of conception until natural death. 28 9. CONCLUSION TO PART TWO The concluding section of the CDF Declaration of Euthanasia provides a fitting summary regarding the truth we have tried to present and proclaim: Life is a gift of God, and on the other hand death is unavoidable; it is necessary, therefore, that we, without in any way hastening the hour of death, should be able to accept it with full responsibility and dignity. It is true that death marks the end of our earthly existence, but at the same time it opens the door to immortal life. Therefore, all must prepare themselves for this event in the light of human values, and Christians even more so in the light of faith. As for those who work in the medical profession, they ought to neglect no means of making all their skill available to the sick and dying; but they should also remember how much more necessary it is to provide them with the comfort of boundless kindness and heartfelt charity. Such service to people is also service to Christ the Lord, who said: "As you did it to one of the least of these my brethren, you did it to me" (Mt. 25:40). 29 28 Ibid, pp.303-305 29 CDF Declaration on Euthanasia, Conclusion