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Death needs no assistants.

The editors interview M. Cathleen Kaveny

When Cathleen Kaveny decided to study ethics, her college professor, the great ethicist Paul Ramsey, told her to do it right. Get a law degree along with your Ph.D., he said; so many ethical questions end up being legal ones. So Kaveny got her two degrees, clerked for the Hon. John T. Noonan, Jr. in San Francisco, and spent three years practicing health law in New England before coming to teach at the University of Notre Dame Law School. She is a member of the Hastings Center Task Force on Managed Care and speaks frequently on health-care ethics and end-of-life issues. In addition to being a practicing lawyer, she is also a practicing Catholic.

Kaveny skillfully navigates the middle course taken by the Catholic Church on end-of-life questions. On the one hand, she explains, Catholics see life as a gift from God, not a personal possession we may terminate at will. On the other hand, we need not undergo extraordinarily burdensome procedures just to preserve life. "We do not have a vitalist tradition that says that we must keep the body going at all cost," she says. "Life is a great gift, but it's not the only game in town. There's a much better game waiting for all of us."

Why has assisted suicide suddenly become such a charged issue for our country? What's changed?

In recent decades, the practice of medicine has so exploded that many things have become possible that were never possible before. Medical advances have made it possible to keep people alive longer but not necessarily in a better condition. Doctors are able to stop a stroke from killing you, but they can't keep it from impairing many of your functions. You may end up on an artificial ventilator or with a feeding tube for the rest of your life.

The culture of medicine, combined with our country's drive for progress, has led us to keep trying to do more, to try newer and more expensive procedures, but we haven't taken into account the human cost. Anyone who's had a family member with cancer or any other long-term health problem knows that it's a real challenge to the soul as well as the body. People have begun to say, "That's enough." Instead of thinking, "How can we cut off the treatment or increase the pain management or bring in some social services?" people have gone to what seems the easiest option: assisted suicide.

I think there's a real problem that has created the demand for assisted suicide; I just don't think it's the right solution to that problem.

How has the medical community reacted to this challenge?

I see two signs of hope. Thanks to the work of religious and secular ethicists like Father Richard McCormick, S.J., Paul Ramsey, and Daniel Callahan, doctors are finally beginning to recognize that patients are not just something they operate on. A new generation of doctors has begun to acknowledge patients as decision makers; they let patients make choices within a range of treatments. They understand that these are not purely medical questions but human questions, too, and that's a good development.

Of course there's still a disparity of power and knowledge, which means patients will always have to rely on the judgments of doctors, but doctors are beginning to see their role as enabling patients, not substituting their judgment for the patients' judgment.

The second sign of hope is that the medical profession is beginning to realize they've got to do a better job of pain management. I'm thinking, for example, of the hospice movement for the dying and of those who are working to improve pain control. We now have techniques that haven't been used as widely as they should be, but at least they're finally getting some attention.

What attitudes in our culture are pushing us toward assisted suicide right now?

We have a fear of pain, a fear of protracted disability, and a fear of imposing too much of a burden and expense on ourselves and our families. But there's another element at work that I'd like to challenge: That's the sense that every single aspect of my body should be entirely under my control. Our attitude is often, "I'm the one in charge, and anything that might affect me is something I could and should be able to decide about."

So what's the problem with that?

From a Catholic perspective--even though it reaches beyond a Catholic perspective--this attitude fails to account for three things. The first is that we're all embodied; our bodies are not just tools of our minds. We all live an embodied human existence that begins and ends. That takes acceptance and learning to deal with our bodily limitations. This doesn't mean that we say, "Suffering is good for you," but it does mean that part of the challenge of living an embodied human existence is learning how to accept and transcend limitations.

Second, we have grown to idolize youth, power, strength, and ability as the norms that all should meet. Unless they can measure up to a fairly narrow parameter of functioning and ability, many people think life isn't worth living, that they'll be too much of a burden on others who will have to take care of them. This cheapens the value of human life, a gift given to us that has value under any circumstances. I think that's very troubling.

Third, I see a disturbing sense of privacy at work, one that says that no one should be able to criticize or critique anything in the range of choices about what one might do with one's life. I would prefer an approach that would bring together our common resources, our common experiences, and our common vision about what it means to die well so we could talk about the ramifications of our choices. If privacy means immunity from a common discussion about something this important, I find that very worrisome.

What is the Catholic position on assisted suicide?

The most important thing to realize is that the church's position on assisted suicide takes place against the backdrop of what human life is and why it's important. We believe that human life is good, that it's a gift from God through which we are called to work out our relationship with God and other people. It's not just a neutral thing over which we have absolute control, which we can accept or reject as we wish. We're called to be stewards of that gift of life. We do have the ability to exercise our own vision and choice and discernment of our own call. But we don't have absolute dominion over our own lives, because we're called to be faithful to that original charge to know one another and to love God and one another better.

Against that background, it's inconsistent with the notion of stewardship for us to take an action that's aimed at ending one's life or the life of another. Such an action would mean that you're completely sure that there's no purpose to this life anymore and that you're just going to put an end to it. That's usurping a decision that's not really yours to make.

How far do you have to go in Preserving your life?

Catholic tradition says that you're obliged to use ordinary, proportionate means to preserve your life, but you're not obliged to use extraordinary or disproportionate means. Sometimes the means used to stave off death come at such a high price that you may decide the benefit doesn't outweigh the burden.

For example, if you needed a heart transplant to survive, but having that transplant meant you'd have to leave your family and move to another city for nine months to be near the surgeon, you could refuse to do that because you decide that the burden outweighs the benefit. The patient is the person in the best position to make this decision because it has to be decided from the perspective of the patient's life.

These decisions can be very complicated. An "ordinary means" for people who don't care where they live or who have a high tolerance for pain will not be an ordinary means for those who have lived their whole lives in a small village and find a shot extremely painful.

There's another set of choices that also don't qualify as assisted suicide. If a doctor gives a patient medication that is intended to alleviate pain but will also suppress respiration and possibly shorten their remaining days or hours, the church does not consider that assisted suicide because the aim is not to cause death. The aim is to relieve pain, and the shortened life is accepted as a side effect of that. You sometimes hear this referred to as the principle of double effect.

Aren't these complicated choices for average people to make?

They certainly can be, and you shouldn't start thinking about them in the middle of a crisis situation. Parishes should be educating people all along about how to make these discernments, about the difference between giving pain medication that might also shorten one's life and asking for a lethal medication because, for example, one has decided that nobody should have to spend the last six months of life wearing a diaper. The second example is certainly a difficult situation that calls for compassion and support, but it still doesn't justify the choice to end a person's life.

What it comes down to is that as Catholics we see life as good but not necessarily an ultimate good. So we take a middle course, as Catholicism does on many things. That's why I think it's so ethically persuasive on many issues.

What do you mean that life is not an ultimate good?

The church believes that human life is a value that must be respected and cared for, but sometimes that can mean recognizing that because someone has started the dying process, it doesn't make sense to hook them up to one more machine. We do not have a vitalist tradition that says that we must keep the body going at all cost. We don't believe that because we know that Jesus died and was resurrected. We have the promise of everlasting life that relativizes the value of this life: Life is a great gift, but it's not the only game in town. There's a much better game waiting for all of us.

What's the difference between refusing a certain treatment in order to let nature take its course and taking a drug prescribed by your doctor to accelerate the process?

I don't think we should focus on whether the physical act itself is active or passive. What is decisive is the mind-set of the person making the decision. The Catholic vision says it's one thing to recognize that God is calling me home now or that the actions I could take to preserve my life would do real harm to other things I value--in this view I'm trying to be a good steward.

It's another thing to say, now that I am no longer continent or have use of my limbs, life is no longer worth living, and therefore I'm going to end it. That decision values individual choice before anything else, whereas the first decision maker values discernment. Discernment takes place in the context of prayer, trying to figure out what your purpose is in light of the options available to you. The problem is that many people say, "These last six months of my life have no value; I'd like to skip the whole process." See the difference in attitude?

So who has the right to say which scenario is better, except God?

That's always a hard question. Catholic teaching has drawn a line saying decisions that aim at ending a life are going too far because the person is making the ultimate decision about the value or nonvalue of a certain level of existence. Are there specific examples that will make this a hard line to hold? Yes. You can always find hard cases that will make you wince. But if you step back and look at the whole picture, the line makes sense.

Doesn't it seem like we're blaming people who can't handle their pain?

This isn't mainly about blame. I don't think the church is saying, here are the rules, and we're going to blame the people who committed suicide because they didn't live up to our abstract rules. Morality is not fundamentally about blame. I think morality is fundamentally about calling us to live in a certain way that will make it easiest for us to appreciate the value of the gospel. If anything, the church blames the rest of us for not providing suffering people with the kind of support they need so they can see their lives are still valuable. It's really more of a challenge to the community than to individual people.

What are some of the dangers inherent in physician-assisted suicide?

There are plenty of secular arguments against it based on the risks involved. Let's say you agree with the position--which is not the Catholic position--that everyone should be able to make a choice about living or dying and have that choice implemented. Now compare the two systems on that basis. In places where assisted suicide is not legal, doctors sometimes have made exceptions in very hard cases. So those people are able to have their choices implemented. Other people in those states might choose assisted suicide, but their doctor will not cooperate. So they are prevented from making that choice.

But let's look at the other side. If you legalize it, we're still dealing with imperfect people in an imperfect world. You now have a great risk that people will lose their choice in the other direction--that they'll be pressured into assisted suicide when they really don't want to do it. So even working with a secular model, the risk of abuse is so great with legalization that more people may really not be able to make free choices about whether to live or die.

How would people be pressured into dying?

It could be as subtle as encouragement from physicians and family members to make that choice. Imagine hearing this: "You've only got six months to live, and they're not necessarily going to be the best six months. I just want to let you know that you have the option of avoiding that problem through physician-assisted suicide. It will be very painless, and it's your right under the law."

Does managed care play a role?

It plays a huge role, because doctors aren't perfect and health-care insurers aren't perfect. Some proponents of assisted suicide talk as if every doctor were TV's old Marcus Welby--a doctor who knew you and your family, who knew what you could bear, and who would help you make this decision about your life. The reality is that most of us are in managed-care plans. We have more distant relationships with our doctors, and our doctors now have financial incentives that could actually encourage abuse in cases like this.

In the old days, Marcus Welby made money every time he saw you, so it was to his advantage to keep you alive. If he were to suggest assisted suicide, at least you'd know he was acting against his own financial interest. Under managed care, the more care physicians provide, the less money they make. That's going to make them look at assisted suicide in a very different way.

What do you think is a good strategy for Catholic Church leaders who speak about this issue in the public square?

I think that Catholics should introduce into the public discussion our wisdom on how to die well. We can offer a real alternative to thinking about death as something to be gotten over with as quickly as possible. Let's start a conversation with questions like: What do we want to do in our dying process? Whom will we make amends to? How will we relate better to God and the people we're connected with? If we could do that, we'd be helping a lot of people.

What leads our culture to say, there's no value in the dying process, so let's get it over with?

It's easier for me to see why Christianity doesn't feel that way, and it's because this is a question of hope, grounded in the Crucifixion and Resurrection of Jesus Christ. If you really believe in that, then you're not going to separate the dying process from the rest of your life. It may be incredibly painful and difficult, but ultimately we have hope that it will be transcended for us just as it was for and through Christ himself. So we have something to hold onto, and we can experience growth from this in ways we can't imagine. The larger culture has lost this sense that each of us in our suffering can connect with a source of life that in the end will overcome our suffering.

The real task for the Catholic Church is to make this plausible without it sounding like a greeting-card sentiment: "Don't worry, everything's going to be better in the end."

Why does the church often seem like a lone ranger speaking out on this issue?

One of the things I like best about Catholicism is that we don't think our obligation is just to ourselves. We think part of our task is to structure the community in a way that recognizes the dignity of every person. Not every Christian denomination sees itself as having that kind of message. Another reason is that in the U.S. at least, we're pretty well organized. We recognize the dangers, we mobilize the resources, and we aren't afraid to speak out.

Why is this such an animating issue for us? On this issue and on abortion, what's at stake for the church is the equal dignity of all human beings--no matter what their status, no matter how young or old they are, whether they're handicapped or not. If you're made in the image and likeness of God, you have a transcendent value that must be respected.

In the realm of public discussion, what are some principles that a person with religious convictions can use to be persuasive to people who don't share those convictions?

I don't think there's any one recipe for this. There are two extremes. One extreme is that any time you enter the public square, you must use purely secular language. You're not allowed to use religious imagery or even religious rhetoric in making your points. When we're trying to persuade people about something that concerns all of us as citizens, some people think we should use a kind of purified language. But I think that's a restriction on our freedom and our ability to come to know one another. I think the public square is enriched when we bring our religious traditions with us.

On the other hand, I think it's counterproductive to go into a discussion like a prophet, saying, the church teaches this or the Bible teaches that and therefore we should all do thus-and-so. Some of your audience doesn't accept the Bible, so you're not having the effect you want, which is to be persuasive.

I think the discussion works better if we draw on our specific rich religious traditions to illuminate ways of looking at life or death.

Sometimes it seems to me that people hold back their religious convictions and only express them when they're least likely to be accepted, which is when we're debating very controversial issues like legislation. If you haven't been sharing your tradition all along, this is the worst time to introduce your religious claims because people have no sense of why you believe what you believe. The only thing you've told them is that your God says they shouldn't be doing something, and why should they care since they don't believe in your God anyway?

What are some principles that average Catholics might adopt for their political involvement?

The Catholic tradition of social justice offers a set of principles that we believe are the best way to organize a society that includes a lot of people who don't think like us.

First is the notion that government is not about just protecting or setting up fences to keep us from harming one another, but it's about fostering a common good. Because we create a community together, we need to be concerned about not what's going to be best for me and mine, but what set of structures will be best for the whole community over the long haul.

Second is the principle of solidarity. If you believe humans are equal in dignity and that we're all brothers and sisters in Christ, that calls for some obligations on our part. We therefore honor the fact that the gifts we've been given are there to help not just ourselves but the more vulnerable people among us.

Solidarity has three components. One, you need to look to the people on the edges of the community. You have to feed them and make sure they have the material resources they need. Two, you have to bring them into the community--it's just not enough to leave them on the margins. And three, which I think is the most distinctive function of solidarity, is that you have to enable people to give to you, because they have gifts, they have talents, they have a vocation, and part of your job is to recognize that you need something from them. This vision of the individual and the community and how we relate may not dictate specific policies on issues, but it affects how you look at a whole range of issues.
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Title Annotation:law professor Cathleen M. Kaveny
Publication:U.S. Catholic
Article Type:Abstract
Date:Jan 1, 1999
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