Protecting the Least of Among Us: The Enduring Universal Wisdom of the Church on Euthanasia
[Keynote Address to Canadian Catholic Bioethics Institute by Gerhard Cardinal Müller]
First, I would like to thank the organizers of this event, the Canadian Catholic Bioethics Institute, including its leadership, staff, board members, and supporters, for inviting me to address you all this evening. I would also like to express my gratitude for my brother Archbishop and your wonderful and faithful shepherd, His Eminence Thomas Cardinal Collins. Your work and witness in promoting and defending human dignity through interdisciplinary ethics research is invaluable, particularly at this moment in your nation’s history when recent laws and judicial opinions threaten to sow confusion and encourage grave violations of man’s intrinsic, inalienable, and equal dignity.
I am referring, of course, to the 2015 decision of the Canadian Supreme Court decriminalizing euthanasia, and the subsequent codification of this result by your Federal Parliament in 2016.
The tragic recent legalization of euthanasia by Canadian authorities is the framing context for my remarks this evening. In my brief time with you tonight, I would like to explore the wisdom of the Church on this issue, which is not only enduring, but accessible and valuable to all reasonable people of good will regardless of their faith tradition.
In particular, I would like to discuss the ways in which euthanasia not only constitutes a grave wrong in itself, but how its legalization creates toxic and deadly social pathologies that disproportionately afflict the weakest members of society. Understanding clearly these individual and social wrongs will illuminate and prepare us for the path forward, namely, to persuade Canadian citizens to take the necessary steps to reverse the dangerous legal error of your Supreme Court and Parliament, and in the meantime, to protect the rights of conscience of health care providers who refuse to take the lives of those that they have sworn to treat and comfort.
To that end, I will proceed in the following way. First, I will offer a brief definition of euthanasia, and distinguish it from the withdrawal of life sustaining measures, which is both ethically and legally distinct. Next, I will show how the case for euthanasia rests on demonstrably false premises. Then I will offer a critique of the case for legalizing euthanasia, first briefly in principle, and then at further length at the level of prudence. This prudential case against euthanasia – framed at the level of public policy – is the most potent argument for a pluralistic society and has persuaded numerous thoughtful people of all (and no) faith traditions across the political spectrum to oppose its legalization. Having thus discussed the grave harms posed by legal euthanasia to individuals and especially vulnerable groups, I will discuss the nature and importance of conscience protections for health care providers. I will briefly demonstrate that doctors and nurses who refuse to participate in euthanasia are not asking for an exemption because of their personal views or values. Rather, they are seeking to practice in the fullest and most faithful sense the medical art that they profess, namely, to seek the good of the patient they have taken an oath to serve.
Euthanasia Defined and Distinguished
In matters of justice and morals, it is essential that we call things by their right names. The use of euphemism or obscure terminology in issues involving life and death should always alert us to an effort to hide the truth. For example, in Canadian public discourse, facilitation of suicide or even direct killing is deceptively termed “aid in dying” – a fabricated expression whose only rhetorical function is to conceal the very nature of the death-dealing action it describes.
For present purposes it is important to be clear eyed and forthright about what euthanasia is and what it entails. Assisted suicide is the facilitation of self-killing, usually by writing a prescription for a lethal dose of medication. Euthanasia is the direct killing of one person by another for the sake of some perceived medical or social benefit. “Voluntary euthanasia” is killing in response to a request to die by or on behalf of the patient himself. “Nonvoluntary euthanasia” is the killing of a person without any request, because the doctor has judged the patient’s life to be no longer worth living. This is most typical in cases involving patients unable to consent, such as the cognitively disabled or infants. “Involuntary euthanasia” is the direct killing of person over his objections, because the doctor involved has decided that the patient’s best interests warrant death to such a degree that he is justified in overriding the patient’s expressed desire to live. It has been reported that in the Netherlands, a doctor surreptitiously euthanized a nun over her objections, and justified it on the grounds that she was mistaken about her best interests due to an irrational and superstitious commitment to religious belief.
We should distinguish assisted suicide and euthanasia from refusal or discontinuation of life sustaining measures. The clear purpose of euthanasia is to kill the patient directly; to bring about his or her death. If the patient survives, the doctor seeking to euthanize him has failed. By contrast, the purpose of refusal or termination of life sustaining measures need not be to cause or hasten death. For example, a patient may simply wish to decline or discontinue a medical intervention that is unduly burdensome or futile. This is not a choice for death as such, but rather a choice against a burdensome or futile treatment, with the likely (though unintended and regrettable) side effect of the patient’s demise. To be sure, there may be other (perhaps many) cases in which discontinuing or refusing life sustaining measures is specifically intended to bring about the patient’s death, and in these cases, such actions are morally indistinguishable from euthanasia. But, as a category, we should treat euthanasia (which always and everywhere aims at death) differently from terminating life sustaining measures, which requires a more searching inquiry to discern its purposes and legitimacy.
Similarly, we should distinguish euthanasia and termination of life sustaining measures from aggressive use of pain treatment through medication and dosages that are dangerous for the patient. In this context, the aim is alleviate suffering through potentially risky means, not to kill the patient.
In short, euthanasia and assisted suicide always aim at killing a person, whereas termination of life sustaining measures may not aim at such a result, and the aggressive use of dangerous pain medication never aims at this result.
Rebutting the Case for Euthanasia: Faulty Premises and Flawed Anthropology
Shortly, I will articulate the case against euthanasia and assisted suicide both in principal and in prudence, but first I would like to demonstrate that the arguments in support of these practices are unpersuasive even in their own terms, as they are grounded in flawed premises and reflect a profoundly misguided conception of human beings and their flourishing.
There are several arguments made in favor of legalized euthanasia, but the two primary rationales are respect for autonomy and compassion for the suffering. Both rationales are internally incoherent and fatally flawed.
First, supporters of legal euthanasia argue that respect for autonomy and self determination entitles individuals to choose the time and manner of their death, especially when faced suffering and profound dependence. Euthanasia advocates attempt to bolster this claim by asserting that this is a decision that only affects the patient and doesn’t cause harm or even involve anyone else.
The first thing to notice about this argument is its detachment from the reality of our shared life. Human beings do not exist as atomized units whose actions are entirely limited to their own sphere of consequences. People exist in embedded relationships to others – families, communities, and nations. Anyone who has ever experienced the suicide of a loved one or even a casual acquaintance knows the profound effects this can have on entire communities. Euthanasia in particular is not a self-contained act. It affects families and communities. It affects the medical community and alters its relationship to patients and the public. In fact, social science evidence has demonstrated that suicide can be “contagious” – causing an increase in the incidence of suicidal impulses and actions in the immediate peer group and community.
More deeply, the premise that the suicidal patient himself is in a position to exercise autonomy in a full sense is detached from reality. Autonomy in this setting is nearly always illusory. The vast majority of persons with suicidal ideation suffer from treatable mental illness, including especially clinical depression. Suicidal impulses are also associated with badly managed but manageable pain. Suicidal wishes likewise emerge from intrinsic or extrinsic burdens, including social, familial or financial. It has been demonstrated that the desire for suicide often departs once mental illness and pain are effectively treated. This is true even among the terminally ill.
Moreover, if the rationale for legal euthanasia is rooted primarily in autonomy, there can be no internally coherent limits on its practice. If the key animating good is respect for self determination, how would it be possible to limit who may access euthanasia or to set boundaries for the legitimate reasons for seeking it? Respect for autonomy alone, for example, would not allow forbidding euthanasia to those individuals who are not terminally ill or subject to intolerable physical suffering. To impose such limits would be to engage in paternalistic judgments that are the antithesis of respect for autonomy. If a person simply wishes to die because he is tired of life, the principle of autonomy provides no grounds for refusal. Thus meaningful legal limits quickly give way. This is already the case in Belgium and the Netherlands, which has seen a rapid weakening of the regulatory strictures on euthanasia. In fact, there is a proposal in one European nation to expand euthanasia to persons over 70 who regard their lives as “complete.” What principle justifies the age limit in question? Certainly not autonomy.
In short, the population of people whose suffering or hopelessness leads them to desire suicide are, as a general matter, not operating at the fullness of their freedom. Thus, the very premise of autonomy as justification for legalized euthanasia is fundamentally unstable.
Advocates for euthanasia also ground their claims in compassion for the suffering and dependent. But this, too, is not a sound justification for legalizing the practice. First, we have seen in those places where euthanasia is legal, there soon follows a system-wide decrease in effective pain management of all patients. For example, the state of Oregon in the U.S. (which was the first state to legalize assisted suicide) performs very poorly relative to the rest of the nation in pain management medicine. This is because once euthanasia is an option, it quickly becomes the path of least resistance for medical decisionmakers, leading to an overall decrease in developing and pursuing creative pain management techniques, which in turn causes a greater measure of suffering overall.
More deeply, the principle that killing is the appropriate response to suffering opens the door to eugenic judgments about quality of life, and quickly leads (as we have seen in the European context) to nonvoluntary and even involuntary euthanasia. In the Netherlands there is the Groningen Protocol for the killing of newborns in the name of compassion. Many of these newborns suffer from spina bifida, and 59% of them are projected to have “long life expectancy.” But through the corrupted notion of compassion, these children are killed on the grounds that their long lives increase their measure of suffering, thus justifying euthanasia. And the Dutch doctor who secretly euthanized the nun over her objections felt justified by compassion in doing so.
In summary, neither the grounds of autonomy nor compassion are factually or conceptually sufficient to bear the weight of the arguments for legalized euthanasia.
The Wrong of Euthanasia in Principle
The Catholic Church has long recognized that every human being, no matter his or her condition or circumstance, is possessed of inalienable and equal dignity. This beautiful truth about the human person and his matchless worth is intelligible and self evident to every person of good will, regardless of faith tradition. In its 1980 Declaration on Euthanasia, the Congregation for the Doctrine of the Faith noted the obvious corollary that “[n]o one can make an attempt on the life of an innocent person without opposing God’s love for that person, without violating a fundamental right, and therefore without committing a crime of the utmost gravity.” Taking one’s own life is thus “often a refusal of love for self, the denial of a natural instinct to live, a flight from the duties of justice and charity owed to one’s neighbor, to various communities or to the whole of society – although, as is generally recognized, at times there are psychological factors present that can diminish responsibility or even completely remove it.” (Id.).
Accordingly, euthanasia and assisted suicide are gravely wrong and unjust for all involved at the level of principle – again, a principle to which all persons of good will can understand and embrace.
Regrettably, for a variety of reasons, not everyone apprehends this truth about the inviolability of human life and the wrong of euthanasia. But the good news is that even for those who support euthanasia in principle (by virtue of the misguided constructions of freedom and compassion noted above), there are prudential arguments against its legalization that are decisive in their persuasive force. It is to these arguments I now turn.
Objecting to Euthanasia in Prudence: The Inevitable Tragic Consequences for the Weakest Among Us
The Holy Father has noted that “assisted suicide and euthanasia are serious threats to families worldwide.” In this, he joins the voice of our Church to those who have recognized that whatever one makes of the conceptual arguments for euthanasia, legalizing its practice is far too dangerous for society, especially for the weakest most vulnerable among us.
In the early 1990s, an advisory committee (The New York Task Force on Life and Law) was convened by the Governor of New York to make recommendations on the legalization of assisted suicide and euthanasia. The Committee was composed of individuals who identified themselves as secular and liberal. They were advising a famously liberal Governor (Mario Cuomo). And they began their deliberations expecting that they would ultimately recommend the legalization of assisted suicide and euthanasia. But when they studied the question carefully and dispassionately, they quickly realized that the toxic and deadly social pathologies that would inevitably accompany legalization were too grave and severe to justify such a course of action.
The committee recommended that assisted suicide and euthanasia should remain illegal, because decriminalizing these practices would inexorably lead to: grave and lethal new forms of fraud, abuse, coercion and discrimination against the disabled, poor, elderly, and minorities; deadly forms of coercion by insurers and faithless family members; corrosion of the doctor-patient relationship; an eventual shift to nonvoluntary and involuntary euthanasia; and widespread neglect of treatment for mental illness and pain management.
It is worth quoting the Committee’s conclusion at length: “We believe that the practices would be profoundly dangerous for large segments of the population, especially in light of the widespread failure of American medicine to treat pain adequately or to diagnose and treat depression in many cases. The risks would extend to all individuals who are ill. They would be most severe for those whose autonomy and well-being are already compromised by poverty, lack of access to good medical care, or membership in a stigmatized social group. The risks of legalizing assisted suicide and euthanasia for these individuals, in a health care system and society that cannot effectively protect against the impact of inadequate resources and ingrained social disadvantage, are likely to be extraordinary.” The Committee was particularly struck by the fact that in the Netherlands, for every three or four instances of voluntary euthanasia, there is one case of killing without consent. In particular, the Committee concluded “if euthanasia were practiced in a comparable percentage of cases in the United States, voluntary euthanasia would account for about 36,000 deaths each year, and euthanasia without the patient’s consent would occur in an additional 16,000 deaths. The Task Force members regard this risk as unacceptable.” In the U.S., there have been cases (in those handful of states that have legalized assisted suicide) in which insurance companies have refused to pay for costly medical treatment, but have volunteered to pay for lethal medication for suicide. There have been examples of family members subtly or even overtly pressuring vulnerable patients into choosing suicide. Indeed, worldwide, there is an epidemic of “elder abuse” – most frequently committed by family members. Legalizing euthanasia dramatically amplifies the risks of this already tenuous and dangerous situation.
The American Medical Association – one of the most esteemed professional societies in the world – has consistently opposed legalization of assisted suicide and euthanasia on the grounds that it profoundly alters the doctor-patient relationship, and offers a dangerous sense of mastery for the doctor frustrated by the inability to find a cure. Giving doctors the freedom to kill fractures the relationship of trust with patients, sowing doubts about devotion to the patient’s best interests.
Finally, we need only look to Europe to see how unstable regulatory limits on euthanasia are. In a very short period of time, euthanasia has been expanded from those with terminal illness or intolerable physical suffering to the mentally ill, the autistic, to children and infants, and even to those who find their lives to be “meaningless.”
In summary, while there may be those in the grip of an impoverished conception of human freedom or compassion who fail to see the principled reasons for opposing euthanasia, all persons of good will should be able to see the profound and inevitable social harms that fall disproportionately on the weak and vulnerable when euthanasia is legalized.
The goodness of a society can be measured by how well it treats and protects its weakest and most vulnerable members. Nations that legalize euthanasia fail to care rightly for the least of our brothers and sisters.
The Nature and Necessity of Conscience Protections for Health Care Providers
Given the gravity of the threat posed by legal euthanasia, it is essential that we work for its reversal in the law. But in the meantime, we must take immediate measures to protect the rights of health care providers who refuse to collaborate in or facilitate access to euthanasia.
This is not simply a Catholic issue. No one who trains and takes an oath to care for the sick should be pressed into ending the lives of the very people that they have promised to serve.
Indeed, a health care provider’s refusal to participate in euthanasia should not be understood as a request for an exemption to an otherwise legitimate regime based on unique and particular beliefs or values. Rather, refusal to engage in euthanasia represents basic fidelity to the very medical art that the physician professes. To compel a doctor to participate in any manner in euthanasia is to force him to cease being a doctor and to betray the very profession to which he has given his life.
Why is this so? At the core of the medical art is a promise to serve the good of this patient. It is a sacred promise by the doctor to use all of his training, education, skill, creativity, and compassion to heal, or where this is not possible, to comfort the patient, and to accompany him in his suffering. To never abandon the patient. To “do no harm,” as the Hippocratic Oath enjoins. Thus, the sole orienting objective is to promote the good of the patient. The good of the patient in the medical context is health and wholeness, as discerned by the physician, in light of his training, experience, and understanding of the patient’s unique circumstances and needs.
To compel a doctor to participate in the annihilation of the patient that he has promised to care for constitutes a grave act of violence and direct corruption of the very logic of the art of medicine. It is, in short, to coerce the doctor to act against the good of the patient, which the doctor has sworn an oath never to do.
It is also unjust to force a doctor to refer a patient to another provider who will act contrary to the good of the patient by ending his life.
Any law that forces a physician to act against what he knows to be the most basic good of the patient – the preservation of his very life, either directly or indirectly, is unjust.
Proper respect for the art of medicine and for the men and women who practice it requires robust protections for those physicians who refuse to participate in euthanasia.
I would like to conclude by thanking you all for your work and commitment to the dignity of every human life and the art of medicine rightly understood. While there are currents in the culture and in the law that undermine the respect for the intrinsic and equal worth of every member of the human family, including especially the weakest and most vulnerable, we should take heart in the fact that the enduring wisdom of the Catholic Church, intelligible to all people of good will, is truer, and better, and more beautiful than any alternative. Share it lovingly and with the serene confidence that through the Risen Christ and the intercession of his Blessed Mother, all things are possible, and we shall prevail.