COMMENTARY
FLORIDA CATHOLIC CONFERENCE

Archdiocese of Miami + Diocese of St. Augustine + Diocese of St. Petersburg + Diocese of Orlando
Diocese of Pensacola/Tallahassee + Diocese of Palm Beach + Diocese of Venice

VOLUME 17, NUMBER 1 / November 2001

This edition of Commentary is a pastoral reflection and was developed at the behest of the Florida Bishops to assist pastors and the faithful in understanding Church teaching on the question of assisted suicide.  It is a collaborative work by Revs. Alfred Cioffi, STD, Steven O’Hala, STD and George Ratzmann, STD.  This document is among many other resources available on the Florida Catholic Conference website under the End of Life Decision section.

INTRODUCTION

Today the issue of physician-assisted suicide [or mercy killing] has become one of the most urgent and prominent medical-moral issues we face in our society. It is one which has already affected so many people, and potentially affects us all. Given the grave importance of this issue, we would like to reaffirm the basic elements of a Catholic approach to this issue. We do so by highlighting and developing three major areas which we feel constitute the necessary framework of such an approach.

I. MEDICINE AS MINISTRY

1. Physician-assisted suicide is not just an individual or private matter, but an issue which involves the character and role of medicine in our society. Therefore, before considering the specific role of medicine in end-of-life situations, we would like to explore the meaning of its ministerial character in the light of our Lord's healing ministry.  From a Christian perspective, medicine is more than a business and healthcare more than a commodity; the medical "art" is principally a ministry which, in effect, continues Christ's healing work.  For those who do not share our faith perspective, we hope that the general concept of "ministry" may still serve as an appropriate paradigm for understanding the task and character of medicine.

2. Jesus' healing work reveals the living presence of God's saving love.  Jesus did not perform healings as a miracle-worker, but as the Son of God who reveals God’s saving love for the world (Jn 3:16-17). Jesus' healing work, then, was an integral part of the gospel he proclaimed, i.e., the "good news" of the presence of God’s Kingdom.  In Lk 4:16-21, Jesus indicates at the outset of his ministry that God's liberating, healing, and saving Spirit (Is 61:1-2) is now upon him; and when the disciples of John the Baptist inquire of Jesus whether he is the awaited Messiah, he cites as evidence that "the blind receive their sight, the lame walk, the lepers are cleansed, the deaf hear, the dead are raised, and the poor have the good news proclaimed to them" (Lk 7:18-23; also Mt 11:2-6).  In the Gospels of Matthew, Mark and Luke, Jesus' public ministry begins with a series of healings, and in the Gospel of John (chapters 9 and 11), the healings performed by Jesus are identified as "signs" of God's saving work.

3. Jesus' healing work affects the whole person, in the depths of his or her relationship to God, self, and others.  The connection which Jesus explicitly draws among faith, healing, and the forgiveness of sins (e.g., Mt. 9:2-8; Mk 2:1-12; Lk 8:26-37), or between conversion and the possibility of healing (e.g., Mt 9:12-13; Mk 2:17; Lk 5:31-32), indicates the deeper meaning of his healing work as the defeat of evil and restoration of well-being, in communion with God and others. Again, Jesus is not a miracle worker, but the Son of God who reveals the fullness and power of God the Father’s love in our lives. The healing which he administers is both a living witness to the power of that love, and a summons to follow him in witnessing to that power as the guiding principle of our lives.

4. The disciples of Jesus are called to share in his saving work, and so witness to the healing effect of his love.  The disciples sent by Jesus, both during his earthly ministry and after his resurrection, are given a share in his authority over evil and its effects, and so are able to heal in his name (e.g., Mk 6:7-13; 16:18; Acts 3:6-16; 4:7-30; 5:12-16). They are not to seek their own will and comfort, but are to place themselves at the service of others in the manner of Christ Jesus, who "came not to be served but to serve, and to give his life as a ransom for many" (Mk 10:45).

5. Ultimately, the fundamental norm of Christian existence is to love as God has loved us in Christ Jesus (Jn 15:12-17), which entails complete self-giving (e.g., Phil 2:5-11), in devoted service to others in need (Mk 12:28-31; Lk 10:25-37; Mt 22:35-40; 25:31-46). Our response to the specific issue of physician-assisted suicide in the next two sections seeks to articulate the implications of this norm for the ministry which medicine must render to dying persons and their loved ones.

II.  THE ROLE OF MEDICINE AT THE END OF LIFE: THE DUTY TO PRESERVE LIFE AND THE LIMITS TO THAT DUTY

6. God alone has absolute and exclusive authority over life and death. In traditional Jewish and Christian theology, the duty to preserve life has been based on the belief in God's absolute and exclusive authority over life and death (e.g., Gen 1: 1-2:24, 19-24; 4:8-15; Ex 20:13; Dt 5:17; 1 Sam 2:6).  God alone has the power and authority to determine when life should end; for us, life is "a sacred trust over which we can claim stewardship, but not absolute dominion"(Catholic Bishops of Florida, Life, Death and the Treatment of Dying Persons, 1989).

7. Faith in the resurrection sheds new light on the mystery of life and death.  The resurrection of Jesus from the dead reveals the transcendent meaning and supernatural end of life.  "I am the resurrection and the life," says the Lord, so that all who believe in him may have a share in his eternal life (Jn 11:25).  In Christ Jesus, the forgiving and saving love of God has overcome the power of sin and death: "Death has been swallowed up in victory ... through our Lord Jesus Christ" (1 Cor. 15:54, 57).  The value of life and disvalue of death here on earth is thereby relativized, since the only absolute is the fullness of God's life in which we are called to share (e.g., 1 Cor. 15:12-57; Rm 6:5-11; 8:18-25, 31-39; 14:7-9).

8. The inherent dignity of the human person requires a profound respect for the life of each person.   Catholic teaching understandably bases its regard for the dignity and sanctity of human life on its belief in the divine origin and end of that life:  Each person is made in the image and likeness of God (Gen 1:26-27), and so is a living image of Christ (Mt. 25:31-46).  "The dignity of this life is linked not only to its beginning, to the fact that it comes from God, but also to its final end, to its destiny of fellowship with God in knowledge and love of him." (Pope John Paul II, Evangelium Vitae [EV], 38).  For those who do not share our faith and its theistic assumptions, we would still maintain that respect and concern for the life and well-being of every person follows from a belief in the dignity shared by all, whatever the basis of that belief.  Moreover, we would also suggest that a shared sense of the inherent dignity of all persons involves a recognition of their essential giftedness, and so a common commitment to respect the life of each and every person as an irreplaceable gift to the human family.

9. Such respect for human life precludes the direct, intentional killing of innocent human beings.   Respect for human life and the dignity of each person, in other words, renders both euthanasia and assisted suicide morally objectionable.  "By euthanasia is understood an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated." (Congregation for the Doctrine of the Faith [CDF], Declaration on Euthanasia, 1980, sec.2; also Pope John Paul II, EV, 65).  Assisted suicide, which concurs "with the intention of another person to commit suicide and to help in carrying it out...means to cooperate in, and at times be the actual perpetrator of, an injustice which cannot be excused, even if it is requested" (EV,66).  There is no justification for directly killing innocent persons, as occurs with euthanasia and assisted suicide.  The life of each person is too valuable and precious a gift to allow its direct and irretrievable violation by others.

10. While the direct taking of innocent life is prohibited according to Catholic teaching, no one is obliged to preserve or prolong life, or avoid death, at any cost. Respect for human life entails respect for death and the process of dying.  The task of medicine is not to prolong the latter unduly, but to ensure that it is as comfortable and dignified as possible. Medicine, in other word, must strive to care even when it cannot cure.  The nature of such care must consider the concrete conditions of each patient, in order to determine "whether the means of treatment available are objectively proportionate to the prospects for improvement" (Pope John Paul II, EV, 65).

11. There is no obligation to use life-sustaining means that are deemed "extraordinary," or "disproportionate" to the expected benefits.  In other words: "A person may forgo extraordinary or disproportionate means of preserving life.  Disproportionate means are those that in the patient's judgment do not offer a reasonable hope of benefit or entail an excessive burden or impose excessive expense on the family or community" (National Conference of Catholic Bishops (NCCB), Ethical and Religious Directives for Catholic Health Care Services (ERD), 1994, 57).  While there is a "presumption in favor of providing medically assisted nutrition and hydration to patients who need it," such a "presumption would yield in cases where such procedures have no medically reasonable hope of sustaining life or pose excessive risks or burdens" (Nutrition and Hydration: Moral and Pastoral Reflections, Resource Paper issued by the NCCB Committee for Pro-Life Activities, 1992, Conclusion).  In every instance, in order to respect the dignity and assure the comfort of the patient, sufficient palliative care must be made available when virtually useless or overly burdensome treatment is refused (see CDF, Declaration on Euthanasia, sec. 4).

12. The use of medication or surgery to relieve suffering or alleviate pain is permitted, even if doing so renders the patient unconscious, or shortens his or her life.  Since the purpose of such means is to relieve suffering, there is no moral objection to their use, even if, as a result, the patient loses consciousness and/or dies sooner than he or she would without them.  Death, in such cases, is the indirect or unintended result of pain management efforts, and not, therefore, an instance of euthanasia or suicide.  Moreover, respect for human dignity and compassion for the suffering of others warrant vigorous attempts to eliminate or at least minimize the physical and emotional pain that burdens people at the end of life.

13. The free and informed decisions of competent adults regarding medical care at the end of life should be respected, as long as such decisions are not morally objectionable.   If the patient is incompetent or unable to decide, these decisions may be either expressed in the form of an advanced directive (living will or durable power of attorney), or made by surrogates such as family members or legal guardians, in consultation with the attending health care professionals.

III. CONCLUDING REFLECTIONS REGARDING ASSISTED SUICIDE

14. "Reflection on the innate dignity of human life in all its dimensions and on the purpose of medical care is indispensable for formulating a true moral judgment about the use of technology to maintain life" (NCCB, ERD, Part Five, Intro.).   Catholic teaching on end-of-life issues like euthanasia and assisted suicide maintains that God alone has exclusive authority over the gift of life; human beings, made in God’s image and likeness, are the stewards of that life.  The Church’s teaching thereby insists on the profound respect and reverence with which human life as gift should be treated at all times.  This teaching also maintains that the self-understanding of medicine is at stake in such end-of-life decisions:  The transition from caretaker to gatekeeper of life and death alters the character of medicine from that of ministry in the service of the patient, to that of mastery over the mystery of life and death as such.

15. Catholic teaching on assisted suicide and euthanasia assumes the crucial distinction between directly or intentionally causing death (i.e. euthanasia) and allowing or permitting death to occur.  This is often framed as the distinction between killing and letting die.  The usefulness and validity of this distinction between direct and indirect means of death in end-of-life decisions has been called into question:  Since life-sustaining treatment can be withheld or withdrawn when it is deemed unduly burdensome or virtually useless, or palliative care administered that may hasten death, then for many people it is no longer meaningful to speak of a moral difference between direct and indirect means of death.  Nevertheless, this distinction indicates two fundamentally divergent ways of relating intentionally to the event of death, namely, as its direct cause or attending caretaker.  Consequently, we believe that it is a distinction which moral and legal deliberation can ill afford to abandon.

16. Catholic teaching seeks to respect both the patient’s right to as dignified and comfortable a death as possible, and the duty of medicine to be the caretaker, not gatekeeper, of the life and death of patients.   By judging the use of life-sustaining technology "in the light of the Christian meaning of life, suffering, and death," Catholic teaching seeks to avoid two extremes: "on the one hand, an insistence on useless or burdensome technology even when a patient may legitimately wish to forgo it and, on the other hand, the withdrawal of technology with the intention of causing death" (NCCB, ERD, Part Five, Intro.).

17. Catholic teaching also seeks to avoid the extreme positions of either reactionary disapproval or uncritical approval.  Issues as profoundly difficult and serious as euthanasia and assisted suicide demands careful and attentive reflection; one's response needs to consider the different aspects of the issue.  As Catholics, we disapprove of these practices not only because they exceeds the legitimate authority of care givers and destroy the gift of life, but in doing so they violate the traditional duty of medicine to "first do no harm" (primum non nocere), and risk tragic and irrevocable social consequences. Who is really competent to determine which requests for assisted suicide should be honored, and what standards or procedures would guarantee that such a decision would always be right?  If there is no such guarantee, how can medicine afford to act as if there was or could be?  Is it realistic to think that economic or utilitarian considerations will never be decisive?  What about the real and dangerous possibility of using medicine to eliminate those whose lives may be considered expendable or worthless?

18. "The request which arises from the human heart in the supreme confrontation with suffering and death, especially when faced with the temptation to give up in utter desperation, is above all a request for companionship, sympathy and support in the time of trial" (Pope John Paul II, EV, 67).  The suffering and pain of those facing death, as well as those who care for them in their dying, cannot be minimized.  For adults facing death, their suffering often begins with the loss of personal control and autonomy, and generally involves progressive physical and/or mental deterioration, as well as an increase in physical pain which may become extremely intense as death approaches; for care givers, the suffering is mostly emotional and psychological, as they watch the condition of their loved one(s) deteriorate.  As the patient's condition continues to deteriorate and lead to increasing levels of pain and discomfort, death may appear as a welcome solution.  Often this impression is expressed in the wish that God would take the person from this life and end his or her suffering.  Catholic practice and teaching hold that, rather than assume absolute authority over the life and death of others in such cases, we act morally and compassionately by offering them sufficient care, support and assistance.

19. Rather than sanctioning ways to end life, medical and legal efforts and resources should be dedicated to providing genuine support and effective care to all who need assistance at this difficult, often frightening, and extremely vulnerable time of life.  The special "arts" of medicine and legislation should be enlisted in making care and support more effective and available, and not in either prolonging the dying process or sanctioning euthanasia, even for seemingly worthy motives.  Let care and compassion be expressed in the ministry we render to all our brothers and sisters in need of help and healing, and not in a presumed mastery over the gift of their lives.

20. As followers of Christ Jesus, we pledge our continued efforts, and the resources of our churches and institutions, to the ministry of healing and caring for our terminally ill brothers and sisters.  Facing "the challenge to be Christ's healing compassion in the world," we offer this pledge of our ministry, "not only as an effort to restore and preserve health, but also as a spiritual service and a sign of that final healing which will one day bring about the new creation that is the ultimate fruit of ministry and God's love for us" (NCCB, ERD, Concl.).  Our efforts are meant to ensure that dying persons will not suffer the indignity of undue prolongation of their condition, arbitrary termination of their existence, or callous abandonment by the community, but rather that they will be fully respected, cared for, and humanely treated as gifted members of God's family.