Spring 2012

Society and Culture

Of Life, Death and Dignity

Thomas E. Fitzpatrick

Among the many social issues we read and hear about today, the subject of euthanasia is perhaps one of the most emotionally charged. Should we seek the right to die on our own terms?

British writer W. Somerset Maugham is said to have quipped near the end of his life, “Dying is a very dull, dreary affair. And my advice to you is to have nothing whatever to do with it.” Many would be quick to agree and would gladly adopt his advice if only it were that easy. More than two thousand years earlier, the Greek philosopher Epicurus suggested that “it is possible to provide security against other things, but as far as death is concerned, we men all live in a city without walls.”

The certainty of death is clear; what we don’t know is how, when and under what circumstances, and that can erode our peace of mind. When hearing of a loved one’s death, we derive considerable comfort from learning that he or she died peacefully while sleeping. We still grieve the loss of those who were special to us, but we find some solace if they didn’t suffer.

The Good Death?

A few hundred years before the time of Christ, the ancient Greeks coined the word euthanatos, “the good death,” and its definition has been debated ever since. Is it an easy death, a natural death or a dignified death? Who decides? Can individuals eliminate the fear and uncertainty of death by taking control of their own demise? Is death by personal design an affront to God—a sin? How much say should people have in determining the circumstances of their departure from this life, and do they have a right to the best medical assistance available if they choose to terminate their physical existence?

The Greek and Roman cultures of antiquity tolerated suicide to varying degrees. In the fifth century B.C.E., however, we find a notable exception: the Pythagoreans, who held that human beings possess immortal souls, appear to have opposed suicide outright.

Other early contributors to the debate were the philosophers Plato and Aristotle. In the Pythagorean tradition, both argued against suicide (though Plato suggested that it might be justifiable under certain circumstances). Their views, which together serve as the foundation of Western civilization’s philosophical tradition, were highly influential.

The Bible includes no explicit statement on the question of whether taking one’s own life is acceptable. Nevertheless the few examples to be found in Scripture are of individuals who had grievously turned away from God: Israel’s King Saul (1 Samuel 28 and 31) and Judas Iscariot (Matthew 27:3–5). Early professing Christian theologians largely built their case against suicide on Plato’s teachings. Augustine of Hippo reinforced the orthodox church’s position on the subject by asserting that God’s command against killing also forbids suicide. In the Middle Ages, Thomas Aquinas further strengthened the prevailing position of Christendom by teaching that self-preservation is a part of natural law.

By the 15th century, however, the Renaissance was introducing new perspectives that challenged the prevailing Christian condemnation of suicide. A renewed interest in scientific discovery and learning promoted rationalism, the idea that reasoning is superior to belief in the supernatural. This introduced individualism—a view of man as an individual in search of liberty from external forces. Thus understanding of “good death” was infused with new ideas and opinions. Some historians see this movement as a reaffirming of Greek and Roman values.

Sir Thomas More’s Utopia, published in 1516, suggested that an ideal society would sanction voluntary suicide: “If the disease is not only incurable, but excruciatingly and unremittingly painful, then the priests and public officials come and remind the sufferer that . . . he has really outlived his own death. They tell him he should not let the pestilence prey on him any longer, but now that life is simply torture he should not hesitate to die. . . . Since his life is a prison where he is bitterly tormented, he should escape from it on his own or allow others to rescue him from it.” It should be said that because More was a noted Catholic, many scholars have concluded that his description of state-sanctioned suicide was a satirical spoof.

English philosopher Francis Bacon is credited with coining the word euthanasia in connection with natural death in the early 17th century. More than a century later, Scottish philosopher David Hume wrote in his essay “Of Suicide” that “both prudence and courage should engage us to rid ourselves at once of existence when it becomes a burden.”

New Considerations

By the end of the 19th century, termination of the hopeless, who were a burden to themselves and society, was openly discussed among the European and American intelligentsia.

In addition to new philosophical approaches to the subject, scientific and technological advances began to reveal the new power of the medical community to overcome disease and prolong life. Antibiotics, vaccines and other medical inventions made doctors look like miracle workers. For many, God was no longer the only one to turn to in matters of life and death. The right to make pronouncements on the sanctity of life, once the sole dominion of the church, clearly shifted to be shared with the secular realm. Not only the matter of suicide but the even more troubling subject of assisted suicide—which for many centuries had had a minor role in the philosophers’ discussions—came to the forefront in some circles. Should physicians, with all their new medicines and technologies, help those who were terminally ill and/or in unbearable pain to end their life on their own terms? In some circles the idea began gaining support.

Advocates of assisted suicide suffered a major setback, however, when the atrocities of Nazi Germany became public after World War II. The horrific accounts of what was perpetrated under the guise of medical research and mercy killing shocked the world. The Nazis used euthanasia as a euphemism for extermination. Their purpose was not to mercifully relieve pain but to purge society of those they regarded as the unwanted. They demonstrated the extent to which science and medicine could be hijacked as hideous instruments of evil.

Still, amazing accomplishments in science and medicine continued. But by the middle of the 20th century, medical advances had become a technological two-edged sword. People lauded the medical community’s increasing capacity to prolong life, but they lamented the murkiness of medical ethics on how and when to use their new prowess. It became clear that prolonged lives weren’t necessarily tolerable lives, and so the concept of a natural death became increasingly confused, a casualty of human ingenuity.

In response to this new reality, Pope Pius XII announced in 1957 that the Catholic Church recognized a dying person’s right to refuse extraordinary medical measures when death was imminent and treatment would only prolong suffering. He also declared that the church would allow for the use of prescribed pain-relieving drugs even if they potentially hastened death, as long as the primary intent was not to end the life. This came to be called “the double effect,” where painkillers are administered ostensibly to relieve suffering with the likely side effect of expediting a patient’s death. The pontiff’s willingness to sanction such “passive euthanasia” is considered a watershed moment, and it reenergized the assisted-suicide debate, which gained momentum during the following decade.

Among the turbulent themes of the 1960s was an increasing emphasis on individual civil rights. This concept was easily extended to a patient’s right to be adequately informed of all medical treatment. It also included the right to refuse prescribed treatment. Since the term euthanasia had been tainted in the Second World War, advocates of assisted suicide now reframed the discussion as an individual’s “right to die.”

The next few decades provided a series of high-profile cases in Britain and America in which the right to die was contested. The public followed the court proceedings closely as these family tragedies revealed the stress and trauma associated with life-and-death decisions. In the United States the matter eventually wound up in the Supreme Court, which ruled that there is no constitutionally protected right to die but also encouraged further debate on the subject.

Active Euthanasia

Today the term euthanasia has come to mean deliberately causing or contributing to the death of a hopelessly ill individual with the intention of relieving misery. Mercy killing, assisted suicide and physician-assisted suicide are closely related terms. Also common are the descriptors active, passive, voluntary, involuntary and nonvoluntary. Active euthanasia involves a deliberate act that directly causes the death of a terminally ill person. So-called passive euthanasia is when medical treatment or life-supporting medical equipment is withdrawn, whether by the doctor’s, the patient’s or the family’s directive. This term is also applied when death is the secondary effect of a doctor’s action (such as the administration of high doses of morphine to control pain). Voluntary euthanasia is done with the consent of the dying person; it is considered involuntary when the person wants to continue living but is euthanized anyway. Euthanasia is nonvoluntary when the consent of the person is neither sought nor given (such as when he or she is comatose or otherwise unable to communicate).

The most outspoken advocate of active euthanasia at the end of the 20th century was Jack Kevorkian, a pathologist from Michigan. Kevorkian pushed the debate to new limits by interpreting an individual’s right to die as an open door to euthanasia on demand. By the end of his career he claimed to have assisted about 130 people in ending their lives with medical devices he designed. The State of Michigan revoked his medical license in 1991 and convicted him of murder in 1999.

At the outset of the 21st century, the Netherlands formally legalized euthanasia after a longstanding tradition of tolerance. Doctors were seen as being caught in an intolerable position, having to choose between two primary though sometimes conflicting medical precepts: to prolong life and to relieve suffering.

But have the results been positive? A December 9, 2009, article in the U.K.’s Daily Mail Online reported, “Legalised euthanasia has led to a severe decline in the quality of care for terminally ill patients in Holland.” The article went on to note that “even the architect of the controversial law has admitted she may have made a mistake in pushing it through because of its impact on services for the elderly.” 

Still, Radio Netherlands Worldwide reported in 2010 that a Dutch pressure group called Right to Die NL was “investigating the feasibility of setting up a clinic for suicide and euthanasia” to help those “who sincerely wish to die and have nowhere else to turn.” Such a clinic would serve those who have chronic mental issues such as Alzheimer’s or who simply “feel they have ‘completed’ their life.” The group would like these clinics to become standard features of hospitals or nursing homes.

Overall, after a decade of experience and mixed reviews, the taboo surrounding mercy killing appears to be fading in the Netherlands. A July 2011 poll of 800 general practitioners found that 86.5 percent were willing in principle to participate in legal euthanasia and 68 percent said they had done so in the last five years. About 89 percent felt that mercy killing has its place in a general medical practice, though most also said they set limits on what they considered to be reasonable grounds.

Presently the Netherlands, Belgium, Luxembourg, Switzerland and Colombia, along with the American states of Montana, Oregon and Washington, are the only places in the world that permit active euthanasia or assisted suicide. Elsewhere, however, pressure to legalize it is mounting.

Life-and-Death Decisions

As the search for the good death continues, everyone uses terms such as compassion, dignity, comfort and mercy. All parties in the debate express a strong desire to relieve excruciating pain and needless suffering.

While a patient’s choice not to accept extraordinary medical measures to prolong life is widely recognized, the pivotal and highly controversial issue is the question of personal autonomy. Should there be limits on self-sovereignty? Or is the view that “it’s my life and I’ll do with it as I see fit” valid? In other words, do personal choice and individual freedom extend to all decisions including the final one to end life on one’s own terms?

The purpose of medicine is not to relieve all the problems of human mortality. . . . [It] has no competence to manage the meaning of life and death—the deepest and oldest human questions—but only some of the physical and psychological manifestations of those problems.”  

Daniel Callahan, The Troubled Dream of Life: In Search of a Peaceful Death  

Those who would answer no typically fear the “slippery slope.” They doubt whether adequate safeguards can be put in place to prevent subtle and not so subtle pressures on the most vulnerable to expedite death and thus relieve themselves and those around them of a great burden. It can be hard to tell whether the decisions of the dying are truly their own or have been engineered by those with vested interests. Will financial and economic concerns, personal convenience and other pressures on time and money play a significant role? Critics cite an increasing rate of euthanasia in the Netherlands as cause for concern.

Are we being seduced into believing that voluntarily terminating life is the best way to deal with the distress of death? After all, great strides have been made in pain management. Many medications are now administered by the patient as needed, thereby eliminating the wait for the next available nurse. The expansion of hospice care, treatment for depression, and other forms of palliative support can alleviate the physical, mental and emotional distress of dying.

The Bigger Picture

As bioethicist Daniel Callahan notes, “the possibilities of inhuman suffering should not be minimized.” He affirms that “a society ought, so far as it can, to work for the relief of pain and suffering; that is to state a simple moral principle. But a more complex principle is needed: a society should work to relieve only that suffering which is not an unavoidable part of living out its other values and aspirations.” What values are being overlooked in the discussion? Callahan suggests that “it is our capacity to learn how to accept what life puts before us, to be open to that which we cannot control, and to embrace the virtues of courage and endurance in the face of evil, that constitutes the greatest value of our lives.”

These are matters of the mind and spirit rather than the physical body. The late M. Scott Peck, author of Denial of the Soul: Spiritual and Medical Perspectives on Euthanasia and Mortality (1997) lamented the lack of spiritual reflection in the current euthanasia debate. As a physician, psychiatrist and theologian, Peck argued that we are more than mere genetic composition, that human beings have a spiritual component and have been created for a purpose: “What I am saying is that there is a missing piece to the picture. A big missing piece. I believe that huge missing piece is God.”

It cannot be fully correct to say that our highest moral duty to one another is the relief of suffering. . . . If we make the relief of suffering itself the highest goal, we run the severe risk of sacrificing, or minimizing, other human purposes.” 

Daniel Callahan, The Troubled Dream of Life: In Search of a Peaceful Death  

Peck acknowledged that human life is full of problems. He called the difficulty of dealing with them “existential pain” and thought it strange that the God who created us for a purpose wouldn’t have a purpose for the existential pain in chronic illness, aging and even death. According to Callahan, “The problem touches on the meaning of suffering for the meaning of life itself . . . : what does my suffering tell me about the point or purpose or end of human existence, most notably my own?”

As the body weakens during the dying process, we are confronted with what really matters most. In experiencing weakness, we search for and can discover a new source of strength (2 Corinthians 12:7–10). Is there a purpose in suffering? God allowed even His Son to learn through suffering (Hebrews 5:7–8; 4:14–16). Our willingness to accept humility and total dependence on God may actually peak in the dying process (2 Corinthians 4:16–18).

The Bible informs those interested in God’s perspective, and it tells us in Exodus 20:13 and Deuteronomy 5:17 that murder—which must be understood to include suicide (self-murder) and assisted suicide—is wrong. God is an advocate of life (Deuteronomy 30:19–20). Those who have entrusted their futures to Him readily acknowledge limits to personal autonomy as well as His vested interest in the outcome of a human life (1 Corinthians 6:19–20; Colossians 3:1–4).

Before embracing the “good” or “easy” death, why not commit to a thorough study of the purpose of life and death with the guidance of God, who reveals death as an enemy (1 Corinthians 15:26) that He intends ultimately to destroy?