Euthanasia.

Part I: Catholic doctrine

Peter Ryan, MA, STL, is director of the Respect Life Office, Archdiocese of Vancouver. In 1996 he earned a licentiate in moral theology from the Pontifical Lateran University. His dissertation was entitled, "The Canadian Debate Over Legalized Euthanasia: A Case Study in Moral Theology:' The following text, based on a speech to a Diocese of London pro-life conference held April 25, 1998, summarizes many of the dissertation's findings.

In the first part of his talk, he presents Catholic teaching on the subject of euthanasia. In the second part, to appear in a later issue, he discusses the debate taking place within Canadian society in recent years. He also assesses the Canadian debate in terms of Catholic moral prinicples.

Abortion and euthanasia

Euthanasia has many similarities to the abortion issue. For instance, both have to do with the taking of innocent human life--abortion at the beginning of life, euthanasia at the end of life.

But there are a few differences. With abortion we do not usually see the child who is killed, whereas with euthanasia the victim is a visible person who is publicly known. This difference makes the euthanasia issue easier to understand. Also, for the most part with euthanasia, there is no debate over the humanity or personhood of the one who is killed. That makes the issue simpler compared to abortion.

However, in some other important respects, euthanasia is more difficult than abortion. It is frequently less easy to say whether a given course of action represents euthanasia. Abortion is more black and white. Abortion is killing, plain and simple. Euthanasia is killing in order to relieve suffering. It is not just killing plain and simple, but killing based on a motive of compassion.

Now compassion is a rather subjective phenomenon; it is not immediately obvious whether someone has killed out of compassion or not. That is why compassion and, more generally, motive, has historically not been part of the Canadian Criminal Code.

Action and omission

This is not the only grey aspect of euthanasia. As traditionally understood, euthanasia can be not only an action, but an omission of an action, one which causes death in order to relieve suffering. That means that withholding or withdrawing medical treatment can be euthanasia, yet not every case of withholding or withdrawing medical treatment that results in death (with the motive of relieving suffering) is an instance of euthanasia. That sounds complicated and, frankly, it is complicated. However, both faith and reason enable us to make sense of it. Moreover, it is possible to make a public policy that is consistent with the truth about euthanasia. In fact that is the case in Canada today. The worry, of course, is that some people want to monkey around with the policy. So we had better understand what euthanasia is and how the law should deal with it.

Catholic teaching

The Church has a precise definition of euthanasia. John Paul II describes it as "an act or omission which of itself or by intention causes death, with the purpose of eliminating all suffering" (Evangelium vitae [Ev], 1995, n. 65). Now perhaps the first question is, whose death, whose suffering? The reference here is to the death of innocent persons who suffer, or are believed to suffer, because they are handicapped, sick or dying. There's a bit of a wrinkle. It's not just about people who are dying; it's about causing the death of people who may only be disabled or who may simply have a chronic malady. Was Tracy Latimer dying? No, she was disabled. Was her death euthanasia? Yes, it was.

Now look at the phrase "causes death." Here we are talking about a moral decision to kill, or to choose death for, an innocent person. In other words we are talking about what the Church means by the term "murder"--which is also what the term traditionally means in the English language: to inflict death upon an innocent person. Euthanasia, then, is a species of murder.

The Church's teaching about murder is, and has always been, starkly simple and clear. Murder is murder. Murder is always wrong--whether the motive is to relieve suffering, or for any other motive, regardless of the circumstances. Why? Because murder, and thus euthanasia, violates the love and justice owed to both God and man. Human life is a gift from God who remains its sovereign; man has no right to deliberately destroy what belongs to God (Catechism of the Catholic Church, nn. 2277,2260, 2258,2280). Moreover, the deliberate killing of an innocent person attacks the dignity and right to life that everyone has as an image of God and as a sacred being set apart by the Creator from all earthly creatures (Gen 1:26-28,2:19-20).

According to Pope John Paul, these truths about why murder is wrong are revealed by our faith, but they are also discernible by human reason. Murder is prohibited by both revealed law (accessible to faith) and by natural law (accessible to reason) (Ev, n. 57).

Not only is all murder, and therefore all euthanasia, wrong; it is gravely wrong. Why? Because "human life--which it destroys--is the basis of all (human) goods, and is the necessary source and condition of every human activity and of all society" (Vatican Declaration on Euthanasia, 1980, I).

In the 20th century the popes have taught explicitly about the evil of euthanasia since Pius XII. However, it is Pope John Paul II who has issued the Church's most formal declaration ever regarding the morality of euthanasia. In his encyclical Evangelium vitae he stated:

"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. This doctrine is based upon the natural law and upon the written law of God, is transmitted by the Church's Tradition and taught by the ordinay and universal Magisterium" (n. 65).

Talk about not evading the issue!

Active euthanasia and euthanasia by omission

So we know the Church looks upon euthanasia as murder and as something gravely immoral. But we still have not quite sorted out when something is euthanasia or not. Let us look at the definition--where euthanasia is defined as "an act or omission." The definition implies that there are two basic forms of euthanasia. I shall refer to these as "active euthanasia" and "euthanasia by omission" (or passive euthanasia). These are terms that have been used by various Catholic bishops, theologians, and philosophers. However, the Church does not have a universal terminology at this point. Nevertheless, the concepts which these terms try to express are set forth in Church teaching.

Active euthanasia is much easier to comprehend than euthanasia by omission. In active euthanasia, the moral agent causes death by positive action, which includes physically inflicting a lethal measure such as with a drug or weapon. Robert Latimer hooked up his truck exhaust so that it would poison his daughter. That was active euthanasia.

It is important to distinguish active euthanasia from certain forms of pain relief that can resemble it. It is possible to administer medication where the purpose is to control pain--for instance, pain associated with cancer. However, the foreseen but unintended side effect of the medication may be to hasten death. Does that mean a physician who administers such pain relief is killing the patient? Clearly not. The intent of such an action is to relieve pain; death is not intended or chosen. Furthermore, relieving pain is certainly a morally licit act. Of course, if a physician uses more medication than necessary to control pain, and thereby brings about death, he would be killing the patient.

This distinction--between killing someone, on the one hand, and doing an act which may simply be good medical care even if its unintended side effect may hasten death--is well founded in Catholic teaching from Pius XII onward. It is often called the principle of double effect. But it is important to note that this same distinction is also well founded in the traditional ethics and laws of our society.

Some ethicists nowadays, however, try to fudge the distinction. They claim that pain relief associated with palliative care is frequently no different from active euthanasia at all, since death is hastened in both cases. Of course, that is a very good argument if you want to justify euthanasia. But it is not very good ethics otherwise, because it overlooks the different intentionalities at work in these two moral choices. In one case the intent is to relieve pain; in the other the intent is to bring about death.

What about euthanasia by omission? First of all, everyone knows that it is possible to kill someone by denying them the means of life as well as by inflicting some lethal measure upon them. Starvation is an obvious example. Now euthanasia by omission can include starvation, but it can encompass other denials of the means to life. In general, in euthanasia by omission, death is caused by deliberately avoiding the use of morally obligatory life-preserving means.

There are two types of omission here: withholding means not yet in use, and withdrawing means already in use. The means of life that could be withheld or withdrawn as part of euthanasia include medicines, technical devices, and surgery, as well as ordinary measures of nursing care--like keeping a room at a safe temperature. If you hide Granny's heart pills so that she will have a heart attack and die, because you figure she is better off dead, that is euthanasia. If Granny is bedridden and you turn off the heat in the middle of the winter and she freezes, that is also euthanasia, if you are trying to put her out of her suffering.

Ordinary and extraordinary means

This kind of distinction between two kinds of means--ordinary, that which if denied involves homicide, and extraordinary, that which if denied does not involve homicide--is centuries old in the Church, and remains valid today.

Yet we still have not answered the question, when are means ordinary and when are they extraordinary? Simply put, means are ordinary when they are useful and not gravely burdensome. They are extraordinary when they are not useful or else are gravely burdensome.

How do we know when a means is useful or not, burdensome or not? The answer is in an amazing faculty that God has given to every rational person: judgement. Sorry, but there are no short-cut lists that we can hand out, listing all the ordinary medicines, surgical procedures, and medical technologies on one side and all the extraordinary means on the other side. Yet our contemporary consumer instinct is to demand: Okay, kidney dialysis, respirator, CPR-ordinary or extraordinary? The Catholic answer is: Sorry, you've got to give more information about the patient's situation. Only then is an answer possible.

If a person living in a rural area needs kidney dialysis but has to travel a huge distance to an urban centre once a week, that's a serious burden, which makes it extraordinary. If someone is recovering from chest surgery and needs a respirator for a few days, that is probably ordinary treatment since it would be useful and not much of a burden. If the heart of a young healthy person has stopped because of suffocation and can easily be restarted through CPR--that is ordinary treatment for the same reasons. If another person is frail, terminally ill, and close to death, CPR is extraordinary because the relative usefulness is doubtful.

Please note: You cannot just say that whatever is artificial-- machinery, medicines, surgery--is automatically extraordinary and is purely optional from a moral standpoint. It is actually quite natural for us human beings to use artificial means of varying sorts to sustain our lives. When we can do so without undue burden, we have a moral obligation to employ the means; otherwise we are being negligent in not caring for the good of human life that God has given us.

Another point of Catholic teaching is that, in deciding whether a given medical means of life may be omitted, the focus is on whether the treatment is futile or burdensome; it is never a question of deciding whether the person's life is futile or burdensome.

Here is where quality of life assessments about people who are disabled or chronically ill can lead to pro-euthanasia decisions. In other words, if people are denied life-preserving medical treatment not because the treatment is useless or burdensome, but because it will preserve the life of someone who is thought to be better off dead, you have a case of not only discrimination but euthanasia. A good example is when children born with Down's syndrome have died after being denied routine surgery to remove bowel obstruction.

In the view of some respected Catholic thinkers, the heart of the euthanasia mentality--whether we are talking about active euthanasia or euthanasia by omission--is this idea that some people are better off dead and it is acceptable to make them dead.

A right to die

Let me say something about the question of consent, refusal of treatment, and advance directives. But before doing so, I want to mention three things about euthanasia.

First, some Catholic moralists have usefully categorized euthanasia as being voluntary, non-voluntary, or involuntary. It is voluntary when a person consents to be killed by another person; it is non-voluntary when the person being killed is incapable of consenting (e.g., a child or an unconscious patient); it is involuntary when the person being killed objects to it.

The second thing I want to note is the similarity of assisted suicide to voluntary euthanasia. The difference is that in assisted suicide the one assisting helps another to take his or her own life by providing the lethal means, such as drugs, without actually administering the means; in voluntary euthanasia a second party administers the lethal means to the one being killed.

Ethically, assisted suicide is completely against the law of God because the person giving the victim a lethal drug or device is implicitly accepting the victim's immoral decision to commit suicide (see Ev, n. 66). According to Catholic teaching, suicide or self-murder is gravely immoral for basically the same reasons that murder is wrong (ibid.).

My third point is that the main argument against Catholic teaching on euthanasia is one of radical individual autonomy. According to this view, individuals have a fundamental human right to make personal choices about matters of life and death. Suicide, assisted suicide, and voluntary euthanasia are all considered as part of a continuum, all being ways of exercising "freedom of choice" and a "right to die." This viewpoint tends to be totally fixated on and obsessed with the fact of choice, to the point of indifference about whether the choice is good or bad for the person.

Catholic morality upholds free will, but sees it as an instrumental good, subject to moral norms concerning the ultimate good of the human person. The Catholic understanding of human dignity is very rich compared to the autonomy-is-all-that-counts type of approach.

The question of consent

I return now to the questions of consent, refusal of treatment, and advance directives. Catholic teaching says that a competent patient is responsible for his or her own life and health and makes the final decision about the medical treatment received (Pope Pius XII, Address to International Congress of Histopathology, 13 September 19S2). That means the patient has a basic right to consent to, and a right to refuse, medical treatment. So there is a legitimate sphere of patient autonomy.

Morally, however, the rights to consent and refuse are qualified. Persons do not have a right of consent to what is intrinsically evil such as euthanasia. Nor do they have a right to refuse ordinary life-preserving treatment, since that would be equivalent to committing suicide.

Care-givers have a moral obligation to respect patient autonomy, and should ordinarily not impose treatment against a patient's wishes. However, they must also refrain from doing what is immoral, which means they must not accede to a patient's wish when the patient is asking the care-giver to do what is immoral. If the patient asks the care-giver to carry out euthanasia or assisted suicide, the care-giver must refuse. This moral requirement can be especially difficult for the care-giver when the patient is refusing ordinary treatment that is already being administered.

If the patient is asking the care-giver to withdraw ordinary life-preserving treatment in order to end suffering, the caregiver is being asked to participate in euthanasia by omission- something the care-giver must never do. Take the patient I mentioned earlier-the one recovering from chest surgery and on a respirator for a few days, which is ordinary treatment under the circumstances. Suppose the patient is having emotional problems and sees this as an opportunity to make a quick exit from life and asks the doctor to pull the plug. The doctor sympathizes and pulls the plug; the patient dies. That is euthanasia by omission. What the doctor should do in such circumstances is try to get the patient help for his emotional difficulties so as to remove the suicidal wish.

Advance directives

Advance directives can be ways for the formerly competent patient to express his or her reasonable wishes regarding medical treatment. Catholic doctrine is not firmly established on the matter of advance directives. But the bishops who have made statements tend to say that care-givers should honour these directives when they are validly executed and when they do not conflict with Catholic morals.

However, I must note that there are two basic forms of advance directive: the durable power of attorney, or health care proxy, where the patient names another person to make decisions about treatment in the event of incompetence; and the living will, where the patient makes advance decisions about particular treatments they want or do not want. Catholic bishops have been quite favourable about the former, but quite negative about the latter type of directive. There are many problems associated with living wills. I would say that the most serious is that they easily lend themselves to being vehicles for euthanasia by omission.

We come to the question of Catholic teaching on euthanasia and the law. For the Church, a law prohibiting murder is indispensable for the common good as well as for the individual good; it must be enacted. Moreover, equity demands that everyone be protected from murder impartially. Consequently, it could be contrary to the right to life and to equity to permit the killing by euthanasia of the sick, dying or disabled, even in the case of voluntary euthanasia (Catechism, nn. 2273, 2237; Ev nn. 7 1-72).

For Pope John Paul II, so flagrantly inhuman and unjust is euthanasia, so detrimental to the common good, that its legalization can never be morally justified, even by appeal to majority will within a democratic system (Ev, nn. 68-7 1). And a law authorizing euthanasia or abortion, he says, is completely lacking in binding moral force and must be resisted (Ev, nn. 72, 73).

"Part II: The Canadian debate" will follow in September 1999.