Euthanasia and Assisted Suicide

Religious communities have vigorously participated in the extensive debate in the United States, particularly in the latter part of the twentieth century, about assisted suicide, especially physician-assisted suicide, and active euthanasia and about whether legal rules and professional norms should be altered to accommodate those actions. Suicide, the act of self-killing, is generally no longer illegal in the United States, although persons attempting to commit suicide may still be involuntarily hospitalized for their own protection. However, both assisted suicide and active euthanasia are illegal in virtually all jurisdictions in the United States. One notable exception is the experiment in legalized physician-assisted suicide that was inaugurated in Oregon in 1998. In general, American religious communities have continued to support legal and professional prohibitions of both assisted suicide and active euthanasia, often for specifically religious reasons but also because of fears about the negative societal effects.

Although the term euthanasia, with its roots in the Greek "eu" (good) and "thanatos" (death), broadly refers to a "good death," it has come to have a more definite meaning in many debates, denoting how the death is brought about as well as the goal that is sought. Thus, active euthanasia is often equivalent to mercy killing. The distinction between active euthanasia and assisted suicide hinges on who performs the final act—the individual whose death is brought about or someone else, such as a physician or a family member. In assisted suicide others may provide considerable assistance to the person wanting to end his or her life, but that person performs the final act. In active euthanasia, however, someone other than the person who dies performs the final act.

In voluntary active euthanasia, the person who dies chooses to be killed by someone else. If suicide, assisted suicide, and voluntary active euthanasia cannot be justified within a particular religious tradition, that tradition will almost certainly oppose nonvoluntary (without that person's will) euthanasia or involuntary (against that person's will) euthanasia.

The term passive euthanasia usually refers to letting patients die, in contrast to actively killing them. Even though most religious traditions eschew the language of passive euthanasia, in order to avoid confusion, they do hold that it is acceptable under some circumstances to withhold or withdraw medical procedures that could prolong life so that death can occur.

Within both Judaism and Christianity (Roman Catholicism, Eastern Orthodoxy, and Protestantism), the wrongness of assisted suicide and voluntary active euthanasia stems from the wrongness of suicide itself. If suicide itself is not justifiable, then assisted suicide and voluntary active euthanasia are not justifiable. Suicide is considered wrong in these traditions because it contravenes important moral laws set by God, who created human beings in his own image and who gives them life (Genesis 1:26 ff).

Metaphors and analogies are central to theistic arguments against suicide. They involve, as Margaret Pabst Battin notes in Ethical Issues in Suicide (2nd ed., 1995), property relationships (for example, life is God's "image," "temple," or "handiwork," or is a "loan" or "trust" from God) and personal and/or role relationships (for example, human beings are God's "children," "sentinels," "servants," or "trustees"). Construing life as a gift invokes both types of metaphors and analogies. Hence, the obligation to protect human life, including one's own, grows out of God's gracious gift of life. According to Evangelium Vitae (The Gospel of Life), a 1995 papal encyclical, "Man's life comes from God; it is his gift, his image and imprint, a sharing in his breath of life. God therefore is the sole Lord of this life: Man cannot do with it as he wills. . . . the sacredness of life has its foundation in God and in his creative activity: 'For God made man in his own image'."

Debates about assisted suicide and euthanasia often probe these metaphors and analogies: Are there limits on what a recipient may do with a gift? If the gift is faulty—for example, an individual may have serious genetic defects—may it be returned or destroyed? Is the gift, which may cause considerable suffering on the recipient's part, then viewed as a way for God to test or educate the recipient? Centrally important in such debates are the evaluation of human suffering—whether it is valued, merely tolerated, or always opposed—and the implications of the quality of life for responses to God's gift of life.

Despite the general widespread affirmation of sanctity of life, human life does not have an absolute value in mainstream Judaism and Christianity. These traditions, for example, permit and even encourage martyrdom in some contexts, usually accept killing in war and in self-defense, often admit capital punishment, and under some circumstances authorize letting terminally ill patients die.

The Roman Catholic moral tradition has strongly opposed suicide, assisted suicide, and active euthanasia, while formulating several distinctions that allow patients to refuse and family members and health care professionals to withhold or withdraw life-prolonging treatment under some circumstances. It specifies the commandment against killing in the Decalogue (Ten Commandments) to prohibit directly killing an innocent human being. The distinction between direct killing and indirect killing is crucial in distinguishing unacceptable acts of suicide, assisted suicide, and active euthanasia, on the one hand, from acceptable acts of forgoing life-prolonging treatment and of using medications that may hasten death, on the other. It is wrong directly to kill a suffering patient even at his or her request, but it may be permissible to relieve that patient's suffering through medications that will probably, but indirectly, hasten his or her death.

Roman Catholic moral theology further distinguishes ordinary from extraordinary or proportionate from disproportionate treatments. If patients forgo ordinary or proportionate treatments, their actions constitute suicide, or if families and clinicians withhold or withdraw such treatments, their actions constitute homicide. However, if patients forgo or families and clinicians withhold or withdraw extraordinary or disproportionate treatments, which are sometimes called "heroic" or "aggressive," their actions do not constitute suicide or homicide. And they may be morally justifiable. In general, treatments with no reasonable chance of benefit or with burdens to the patient and others that outweigh their benefits may be considered extraordinary or disproportionate and thus may be forgone, withheld, or withdrawn without incurring a moral judgment of suicide or euthanasia.

Despite the great variety of Protestant denominations, there is widespread, but by no means universal, opposition to assisted suicide and voluntary, active euthanasia among denominational statements and theological writings. Some Protestants contend that suicide is wrong because it violates biblical rules against killing, while others hold that it is wrong because it displays a lack of gratitude toward, trust in, and faithfulness toward God as creator, preserver, and redeemer.

Much Protestant reflection on the subject has emerged from individual theologians. Two prolific and influential writers in biomedical ethics—Paul Ramsey and Joseph Fletcher—represent the two ends of the spectrum of Protestant positions on the weight or strength of the rules against suicide, assisted suicide, and active euthanasia. In general Ramsey viewed the rules as absolute, while Fletcher viewed them as mere guidelines. A proponent of "situation ethics," Fletcher defended suicide and active euthanasia in some situations, in part because of the value of personal choice and because of neighbor-love, which he identified with the principle of utility (the greatest good for the greatest number). By contrast, Ramsey in The Patient as Person (1970) rejected both suicide and active euthanasia because these acts contradict the meaning of neighbor-love and transgress important moral limits.

Other recent Protestant opponents of assisted suicide and voluntary, active euthanasia include Arthur Dyck, Stanley Hauerwas, William May, Gilbert Meilaender, and Allen Verhey, while defenders include James Gustafson and Lonnie Kliever. In volume two of Ethics from a Theocentric Perspective (1984), Gustafson contends that "[s]uicide is always a tragic moral choice; it is sometimes a misguided choice. But it can be, I believe, a conscientious choice. . . . Life is a gift, and is to be received with gratitude, but if life becomes an unbearable burden there is reason for enmity toward God."

Like Christianity, Judaism is not monolithic; there are variations among Orthodox, Conservative, and Reform branches of Judaism. In general, the Jewish tradition rules out both suicide and active euthanasia because of its conviction that human life is created in the image of God. It holds that the duty to protect human life takes priority except where murder, sexual immorality (i.e., incest or adultery), or idolatry would be required in order to discharge that duty. Traditionally, it has required that nothing be done to the dying person that might cause or hasten death—for example, closing the patient's eyes or removing a feather pillow from under the patient's head. However, the tradition distinguishes actively hastening death, which is prohibited, from removing impediments or hindrances to death, which is permitted, but only for a person who is in his or her death throes.

Much of the discussion hinges on the conception of the dying person whose death is considered imminent (within three days, according to some authorities). Only a patient whose death is imminent and irreversible may be allowed to die under carefully drawn circumstances. Debates center on what kinds of impediments to death may be removed as well as the circumstances under which they may be removed.

In general, Islam's opposition to assisted suicide and voluntary, active euthanasia is similar to dominant positions in Judaism and Christianity, while both Hinduism and Buddhism have more ambiguous positions—for example, Hinduism and Buddhism have historically accepted some acts of suicide, such as those of holy men, but there is vigorous debate about whether such precedents can extend to assisted suicide and voluntary, active euthanasia as they are currently conceived and practiced.

Much of the debate in the United States in the late twentieth century has focused on whether laws should permit or regulate assisted suicide and voluntary, active euthanasia rather than continuing to prohibit them. While there is a rough correlation between moral judgments about such acts and moral judgments about laws regarding them, the latter judgments are more complex. According to sociologist Andrew Greely, opinion polls suggest that in recent decades there has been a substantial increase in support among religious believers for legalization of physician assistance in ending life.

Not all arguments by religious thinkers or communities for or against legal prohibition are themselves religious arguments. Proponents of legal prohibition frequently appeal to the probable negative consequences of permissive laws, including the difficulty of drawing and maintaining defensible lines, the dangers of abuse, especially because American society often devalues the elderly and fails to provide universal access to health care, and the risks of creating or extending what the Vatican calls a "culture of death." By contrast, opponents of prohibition generally believe that these dangers are exaggerated and/or that strong regulation could reduce their threat.

See alsoBioethics; Death and Dying; Ethics.

Bibliography

Campbell, Courtney S. "Religious Ethics and Active Euthanasia in a Pluralistic Society." Kennedy Instituteof Ethics Journal 2 (September 1992): 253–277.

Childress, James F. "Religious Viewpoints." In Regulating How We Die: The Ethical, Medical, and Legal IssuesSurrounding Physician-Assisted Suicide, ed. Linda L. Emanuel. 1998.

Dorff, Elliot N., and Louis E. Newman, eds. Contemporary Jewish Ethics and Morality: A Reader. 1995.

Greely, Andrew. "Live and Let Die: Changing Attitudes." Christian Century 108 (1991): 1124–1125.

Hamel, Ronald P., and Edwin R. Dubose, eds. Must WeSuffer Our Way to Death? Cultural and Theological Perspectives on Death by Choice. 1996.

Kilner, John F., Arlene B. Miller, and Edmund D. Pellegrino, eds. Dignity and Dying: A Christian Appraisal. 1996.

Reich, Warren T., ed. Encyclopedia of Bioethics. 2nd ed., 1995.

James F. Childress