Case Study sheet
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Physician-Assisted Suicide and Euthanasia: Theological and Ethical Responses
DANIEL P. SULMASY* Georgetown University, Washington, DC, USA
*Address correspondence to: Daniel P. Sulmasy, MD, PhD, MACP, Director, Kennedy Institute of Ethics, Georgetown University, Healy 419, 3700 O St., NW
Washington, DC 20057, USA. E-mail: sulmasyd@georgetown.edu.
Euthanasia and rational suicide were acceptable practices in some quarters in antiquity. These practices all but disappeared as Hippocratic, Jewish, Christian, and Muslim beliefs took hold in Europe and the Near East. By the late nineteenth century, however, a political movement to le- galize euthanasia and physician-assisted suicide (PAS) began in Europe and the United States. Initially, the path to legalization was filled with obstacles, especially in the United States. In the last few decades, how- ever, several Western nations have legalized euthanasia, and several US jurisdictions have now legalized PAS, giving state sanction to these once forbidden practices. With increasing social and political pressure to ac- cept PAS, Christians need to understand how to think about this issue from an explicitly Christian perspective. Independent of the question of legalization, there are significant theological and ethical questions. This special issue aims to address those concerns, including: how does the practice of PAS or euthanasia impact our attitudes toward death, and what does it mean to “die well?” Should physicians, as healers, be in- volved in assisting patients who wish to bring about their own death? Are these methods significantly distinguished from other ethically justi- fied practices in end-of-life care that also lead to a person’s death? Can Christians, both as patients and practitioners, justify the use of these methods to relieve suffering in this manner as compatible with the faith? Although these questions are not new to the debate, it is increasingly im- portant that these controversies are addressed as the practice of PAS is popularized.
Keywords: Christianity, euthanasia, physician-assisted suicide
Through a generous grant from the McDonald Agape Foundation, a series of annual conferences convened to examine controversies in Christian thought
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regarding medical care at the end of life. The third of a planned total of five such conferences took place at Georgetown University in November 2018, gathering professionals from a diverse set of backgrounds who drew from both historical and contemporary sources to explore the ethics of physician- assisted suicide (PAS) from a variety of Christian perspectives. This special issue is the fruit of papers initially presented at that conference.
Euthanasia and rational suicide were acceptable practices in some quar- ters in antiquity. These practices all but disappeared as Hippocratic, Jewish, Christian, and Muslim beliefs took hold in Europe and the Near East. By the late nineteenth century, however, a political movement to legalize euthanasia and PAS began in Europe and the United States. Initially, the path to legal- ization was filled with obstacles, especially in the United States. In the last few decades, however, several Western nations have legalized euthanasia, and several US jurisdictions have now legalized PAS, giving state sanction to these once forbidden practices. With increasing social and political pressure to accept PAS, Christians need to understand how to think about this issue from an explicitly Christian perspective.
Independent of the question of legalization, there are significant theolog- ical and ethical questions. This special issue aims to address those concerns, including: how does the practice of PAS or euthanasia impact our attitudes toward death and what it means to “die well?” Should physicians, as healers, be involved in assisting patients who wish to bring about their own death? Are these methods significantly differentiated from other ethically justified practices in end-of-life care that also lead to a person’s death? Can Christians, both as patients and practitioners, justify the use of these methods to re- lieve suffering in this manner as compatible with the faith? Although these questions are not new to the debate, it is increasingly important that these controversies be addressed as the practice of PAS is popularized.
In the first essay of this issue, Lloyd Steffen presents a possible Christian defense of PAS, arguing that, although “a broad Christian perspective would insist on at least a presumptive opposition to assisted suicide . . . the central moral issue is whether assisted suicide should be opposed abso- lutely or presumptively” (Steffen, 2021, 230). Rejecting absolutism in ethics, Steffen argues that a “presumptive prohibition” on assisted suicide must also recognize that there are morally complex situations in which what should be done is not clear. Steffen argues for acknowledging that assisted sui- cide is prima facie wrong, while also holding that there might be justifiable exceptions. Appealing to a particular way of thinking about natural law, and making an analogy with just war theory, Steffen defends PAS while remaining committed to Christian values. Ultimately, Steffen argues that the world is a messy place, that moral purity is unobtainable, and that sometimes human beings do things (like developing life-sustaining medical technologies) that lead to unforeseen and problematic consequences. He argues that human beings are responsible for those consequences and are therefore obligated,
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from a moral point of view, to devise ways of being accountable to the duty to respect all persons and their individual freedom––a duty that holds even when they find themselves in unacceptable circumstances and make per- sonal choices with which we might disagree.
Teaming up to offer an account from both medical and philosophical perspectives, Farr Curlin and Chris Tollefsen (2021) challenge the medical profession’s increasing acceptance of so-called “physician aid-in-dying”. They argue that the acceptance of PAS is a symptom of the ascendancy of a “provider-of-services” model for medicine, in which “providers” offer serv- ices to help patients maximize their “well-being” according to the patient’s preferences. They contrast this consumerist model with what they call the Way of Medicine, in which medicine is understood as moral practice oriented to the patient’s health. They note that a refusal intentionally to harm or kill is a touchstone of the Way of Medicine, one unambiguously affirmed by Christians through the centuries. Moreover, physician aid-in-dying contradicts one of the distinctive contributions that the Christian era brought to medi- cine: a taken-for-granted solidarity between medical practitioners and those suffering illness and disability. Insofar as medical practitioners cooperate in aid-in-dying, they turn away from this solidarity and undermine the trust that patients need to be able to have in them when they are sick and debilitated.
My own essay follows, in which I offer a counter-argument to one of many contemporary critiques of opposition to PAS—namely, that there are no rational grounds for making a moral distinction between killing patients through the administration of lethal overdoses and allowing them to die by discontinuing life-sustaining treatments (Sulmasy, 2021). I res- urrect Augustine’s distinction between martyrdom and suicide to argue that the distinction between killing patients and allowing them to die has the same logical form: it is sometimes permissible to suffer a harm when it is not permissible to inflict a harm. Just as true martyrs accept their in- evitable deaths at the hands of their oppressors but do not provoke their oppressors into killing them, so it is permissible to accept one’s inevitable death from disease but never permissible to bring one’s own death on oneself. The distinction in both cases turns importantly on intention—one cannot make one’s death one’s direct aim, but one can accept a death that is brought on by forces outside one’s control, whether originating in indifferent nature or in sinful human will. I end by suggesting that in forgoing life-sustaining treatments, one may be understood as accepting one’s death as an inevitable biological event, while not submitting to death as a personal event by refusing to make death one’s direct intention. I con- clude that this might constitute a realization of exactly the sort of coinci- dence of opposites that theologians like Karl Rahner (1961) held out as the Christian ideal.
Devan Stahl argues in her essay that Christians have good reason to “faith- fully attend to the concerns of disability advocates” in PAS debates, and that
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“there is a Christian obligation to attend to the voices of persons whose experiences in health care shed light on the pressures vulnerable people feel to end their lives” (Stahl, 2021, 280). She begins her essay with an ac- count of “disability moral psychology,” which elucidates the unique ways persons with disabilities perceive the world, based on their phenomenolog- ical experiences. Stahl then explores the disability critique of PAS, situated in the shared social conditions of persons who are chronically disabled and terminally ill. She argues that “to bear witness to a compassionate God, the- ological and ethical judgments concerning PAS must seek perspectives from persons who claim that their dignity and even their lives are in jeopardy by the practice” (Stahl, 2021, 281). Stahl thereby hopes to teach all Christian ethicists lessons derived from a conversation with the disabled community.
In the last essay in this special issue, Darlene Weaver (2021) argues that situating PAS arguments within the context of the broader “culture wars” obscures an under-acknowledged consensus—both advocates and proponents appeal to respect for persons. This leads her to suggest that a personalist approach to PAS might deepen standard arguments against PAS in a constructive manner that has a prospect of winning over proponents. Christian personalism, in her view, situates PAS within the larger moral obligations of solidarity with the dying and their caregivers. As such, per- sonalism might serve to relocate debates over PAS and allow all parties to harness shared moral impulses. This approach also invites opponents of PAS to engage advocates more charitably and to forge opportunities that allow deeper insights into human existence, suffering, and death.
By refraining from the direct invocation of the more familiar Christian arguments against suicide, such as the idea of life as a gift from God, or the concept of human dignity as the inviolable stamp of the divine image on the human form, these essays enrich the Christian discussion of PAS. They draw deeply from traditional Christian sources, yet explore the question in novel ways. Nonetheless, even Steffen’s idea of a rebuttable presumption against PAS seems dependent on the idea that human life is a great good that cannot be contravened without an incredibly important justification. As Weaver points out, all of the authors believe that Christian charity demands solidarity with the sick and attention to their needs as persons. All acknowl- edge the facts of human suffering and mortality and the need for Christians to accept death as a biological event, just as Jesus did on the cross.
Each of the authors except Steffen, however, would argue that one can never directly intend to make sick, disabled, or terminally ill persons dead, or assist such persons in making themselves dead. Aiming at death contravenes the good of life, undermines the trust that the sick and disabled need to have in the medical profession, and weakens the bonds of social solidarity that Christ taught us constitute His Body. These essays enrich the Christian liter- ature on this perennially important topic, extending the range and depth of
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the human and Christian considerations that ought to inform our choices as we die or care for those who are dying.
ACKNOWLEDGMENTS
Special thanks to MaryKate Gaurke for her superlative assistance in editing this volume and to the McDonald-Agape Foundation for their generous sup- port of this project.
REFERENCES
Curlin, F., and C. Tollefson. 2021. Medicine against suicide: Sustaining solidarity with those diminished by illness and debility. Christian Bioethics 27(3):250–63.
Rahner, K. 1961. On the Theology of Death. New York: Herder and Herder. Stahl, D. 2021. Understanding the voices of disability advocates in PAS debates. Christian
Bioethics 27(3):279–97. Steffen, L. 2021. Physician assistance in dying: An option for Christians? Christian Bioethics
27(3):228–49. Sulmasy, D. P. 2021. Killing and allowing to die: Insights from St. Augustine. Christian Bioethics
27(3):264–78. Weaver, D. 2021. The case against physician-assisted suicide: A personalist approach. Christian
Bioethics 27(3):298–311.
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