Euthanasia, Physician-Assisted Suicide, and the Pursuit of Death with Dignity
By Fr Joseph Woodill
For a number of years I have worn two hats. At a nearby college, I am Dr. Woodill and teach a very popular course on death and dying. Elsewhere, I am Fr. Joseph. As the priest of an older parish, I have buried more people than seems right. I have also attended to their dying. These days many of the young and oldthe Orthodox and the not so orthodoxseem to me to hold the same perspective on death and dying. Many insist that one ought to be able to die when and how one wills, and that doctors who assist such dying are only helping us. This is, I teach, a dramatic turn from what was once the usual attitude toward dying.
There is no better history of views about death than The Hour of Our Death by Philippe Aries (Oxford Univ. Press, 1981). In tracing 1,000 years of changing attitudes toward death and dying, Aries finds ours to be an age unlike any other. While past generations sought for a good death by living well, putting affairs in order, and living in the knowledge of the inevitability of death, our age is characterized by denial. We have no “art of dying,” so typical of other times. We have, instead, sought to grasp the measure of death by denying it any place, any meaning, and by rendering it a problem to be solved.
The Medicalization of Death
The medicalization of death resulted in death becoming a medical problem to be solved, or if it could not be solved, to be controlled by our technology, by mercy killing. An excellent presentation of this transformation is Daniel Callahan’s The Troubled Dream of Life: Living With Mortality (Simon and Schuster, 1993). As Callahan explains it, we have, unsuccessfully, tried to measure death by a vision of life that demands control and autonomy. We have sought to kill death by making it a medical problem to overcome, by calling lawyers to write documents that will control it, and by evolving funeral practices that allow us to disassociate ourselves from dying.
If the history of our changing grasp of death is old, the story of the contemporary problem is no more than about twenty years old. It seems to me that our views began to evolve at about the time (1976) that a New Jersey Court ruled on the case of Karen Ann Quinlan. The court ruledrightly, it seems to methat she could be removed from the respirator because we ought not to use medical technology to make dying even harder. Medicine is good, but medicine should not contribute to a death without human dignity.
After the court ruled in the Quinlan case that we need not take extraordinary measures to keep those dying alive, the same New Jersey Court ruled in 1985 (in the case of Claire Conroy) that nutrition and hydration (artificially administered food and water) should be treated like any other sort of technology and, so, may also be removed when a patient is dying. The U.S. Supreme Court upheld a Missouri Court ruling (in the case of Nancy Cruzan) that hydration and nutrition could be removed, but only if there was a clear indication that it was the patient’s will. In the light of the ruling on the Cruzan case, Congress passed (Dec. 1, 1990) the Patient Self-Determination Act which required institutions receiving government funding to advise patients that they had the right to indicate in advance how they wanted to be treated.
We know advanced directives as “living wills.” This is a document that attempts to specify what you would want to be done for/to you concerning life-sustaining treatments. It is often combined with a ‘durable power of attorney” that designates a proxy, someone to speak for you. While the living will attempts to insure that medicine will not distort our dying, it has failed to keep its promise. For many reasons, advanced directives fail to insure a death with dignity. Not surprisingly, the document has yet to be written that can insure against the omnipresent ambiguities of life. It will require more than a document to die well.
Even if we could, however, we wouldn’t want to live in a world without modern medicine. Medicine is a blessing and honorable work. I think that the question is, What sort of people do we want to become? and What sort of medicine do we want to practice? We have great faith in technology, but should we expect medicine to underwrite our demands to be in complete control? Since death has proven difficult to control technologically, it follows almost necessarily for some, that they would try to control death by deterring when they will die! Euthanasia seems an almost inevitable consequence of their strategy of avoidance.
Physician-Assisted Suicide and Euthanasia
Living wills and the refusal of life-support technology generally have legaland religioussanction. Physician-assisted suicide (where the doctor supplies the cause of death) and voluntary euthanasia (where the physician performs the act resulting in death), however, have recently been scrutinized.
Two cases came before the US Supreme Court in June 1997. A Washington State law had prohibited doctors from granting patients’ requests for assisted suicide. That state law was declared unconstitutional by the Ninth Circuit Court on the grounds that it violated the guarantee of personal liberty in the Fourteenth Amendment to the Constitution. A New York State law, declared unconstitutional by the Second Circuit Court of Appeals, distinguished between what physicians “passively” allow (letting die) and what they might “actively” cause, i.e. supplying an overdose for a requested suicide.
The Supreme Court, in a unanimous decision, ruled in the summer of 1997 that the Constitution does not guarantee a right to commit suicide with the help of a physician. While the decision allowed states to ban assisted suicide, the same decision also left the states the power to legalize the practice. Justice Sandra Day O’Connor left open the possibility that the Court might yet find a right to suicide for some individuals.
The justices did stresscorrectly, and as I see it, importantlythat there is an interest in protecting against potential abuses. They also saw danger in undermining the trust we have that a physician will not harm us by blurring the line between healing and harming. Neither side of the debate thinks that the Court has solved the problem. The battle has just begun.
There is no figure more emblematic of euthanasia than the Michigan pathologisthe is NOT a family doctor with patientsJack Kevorkian. While many have seen him on the evening news, few bother to read his claims. Prescription Medicine: The Goodness of Planned Death by Kevorkian (Prometheus Books, 1991) is, strangely, dedicated to the enlightened doctors of Hellenistic Alexandria and medieval Armenia. In one of my “favorite” chapters, Chapter 17, Kevorkian declares that a positive result of euthanasia would “allow doctors for the first time to carry out on living human beings otherwise impossible trials of new and untested drugs, devices, or operations” (p. 240). What, he says, prevents the broadening of the spectrum of medicine to include the wonder of “obitiatry” (his word), that is, of experimenting on the dying? Only “the inflexible and harshly punitive Judeo-Christian dogma that espoused the absolute and inviolable ‘sanctity of human life’” (p. 240). Still there is hope, he writes. We may yet overcome “vestiges of those taboos (that) have endured to our ‘enlightened’ time” (p. 240). Even my students, predisposed as they are to applauding euthanasia, cannot believe that Kevorkian wrote this.
I recommend the Armenian Orthodox theologian, Vigen Guroian, as an antidote to Kevorkian. Read the short (about 100 pages), but potent, Life’s Living Toward Dying (Erdmans, 1996). Guroian unpacks a central Orthodox Christian virtue, “the remembrance of death,” to critique Kevorkian and the Thanatos Syndromethe right to put to death with dignity. Guroian is profitably read along with Callahan (noted above). Callahan tries to recover a vision of medicine from the perspective of the reality of death, while Guroian shows how the Christian life requires the virtue or skill of “living toward dying” (p. 35).
Orthodox Christian Ethics
“Orthodox Christian ethics,” writes Orthodox theologian Fr. Stanley Harakas, “rejects euthanasia; it considers it a special case of murder if done without the knowledge and consent of the patient, and suicide if it is requested by the patient” (p. 129 in Living the Faith, Light and Life Publ. Co., 1993). While the position of Orthodox Christianity is clear and unambiguous, I want to suggest another way of engaging these concerns. Both Callahan and Guroian, each in his own way, are engaged in a classical approach to ethics. Both are Virtue Ethicists. Such ethicists ask questions like: What are we trying to become? What are the practices and virtues (skills) that will move us toward our goal? In what sort of world do humans flourish and grow?
Similar questions might be asked of those favoring euthanasia and assisted suicide. For example, what sort of people would create a culture, a world, where our mortality can be ignored? Surely, not people who will die! What sort of medicine would be favored by a people who refuse to face their mortality? Perhaps a medicine that kills! Doesn’t a doctor who assists in the death of his patients do to medicine what a confessor who gossips does to ministry?
I want to suggest that we Orthodox learn to ask questions of virtue like those asked by the Church Fathers. I recommend John Climacus’ The Ladder of Divine Ascent (Paulist Press, 1985). This book is, after the Bible, the most popular and most translated work in Orthodoxy. In The Ladder, St. John of Sinai tells us that the Christian life is like climbing a ladder from where we are (far from being witnesses of God’s ways) to where we ought to strive to be (loving with God’s own love). The goal of life is not autonomy, control, or escape. The goal of life is God; the God who loves by giving Himself, His life to us and for us. Virtues are needed in order to climb this ladder.
Cultivating a “Remembrance of Death”
We ought, for example, to live in a way that cultivates the virtue or skill of “remembrance of death” (Step 6 on the ladder). We must become skilled at remembering that we are not life, or the source of life, and that anything not of God is our death.
We are also encouraged to break free of gluttony. Gluttony is not only - or even primarily - about food. It is when we have learned the habit of making everything a “feast” for ourselves. People growing toward the Lord gain just the opposite virtue. God makes Himself to be a feast for others, as we ought to.
What sort of medicine would people climbing a ladder to our God want to develop? We would surely want medicine to be a craft that comforts, heals, and relieves pain. We would, however, reject a craft developed to make of life a masquerade, pretending that we are able to avoid all suffering. We would not want a medicine that prompts us to neglect living the sort of life that would allow us to face death with peace.
While documents such as living wills seem to me to be a sincere plea that medicine not be used to make my dying harder than the living, we still would not want a world that tells us to trust in a document to insure what only a life well lived can grant. I want to be able to die in such a way that the pain does not preclude my asking for forgiveness. I want to be, God willing, conscious and with my wife, children, and friends. I want my life and death to have been in some way a blessing, so that others are able to relate to my funeral. We should not only want to have, but help to create a medicine that is part of our climbing the ladder toward God’s ways, thus toward being fully human.