Euthanasia and Life-Support Systems
An exploration of some of the ethical-theological criteria involved in the debate on euthanasia and life-support systems
Some context
I was a student in a postgraduate B.A. Honours course in 1988 - Medical Ethics and a Theology of Health - which comprised twelve (12) weekly seminars held each Wednesday.
Half the seminars were devoted to questions of ‘Medical Ethics’ and covered themes which included: the relationship between patient autonomy and a doctor’s responsibility to heal, the theological-ethical issues and criteria involved in procreation, euthanasia and life-support systems, ethical criteria which ought to inform financial resources allocated to medical care, and what it means to tell the truth in a doctor-patient relationship.
The other half of our seminars centred around ‘a Theology of Health’ which included: what are the distinctive characteristics of a Christian theology of health? The significance of the holistic paradigm for understanding health and healing in our context (including dialogue with a biblical perspective, traditional African religion and scientific medicine), faith and the relationship among faith, science and healing, the nature of guilt and its effect on health and the relationship between forgiveness and healing, the theological insights which the Christian faith provides for thinking through the problem of innocent and unjust suffering, and how the Christian tradition understands death and the ways in which this helps in counselling both the dying and the bereaved.
I learnt a good deal throughout this course. To this day I value the content and the kinds of questions we needed to grapple with. I’ve returned to these seminar papers over the years and more especially in more recent times as I have continued to find insights which could support me in my understanding of issues related to Medicine, Science, and Health. I think specifically of the last few years when a so-called ‘Covid Pandemic’ has been forcefully thrust upon humanity across the world, and which has brought into sharper focus many questions and concerns related to (mainstream) medicine, science and health. Even now, four years on, we continue to be bombarded by competing and contested narratives – with a discernible and raging tension between what may be described as Good and True medicine, science and health, as distinct from Bad or Pseudo medicine, science and health.
My focus will now shift to issues covered in the Medical Ethics component of the 1988 course. In separate substacks, I will touch on themes that include: the relationship between patient and doctor (autonomy and beneficence), procreation (abortion and in vitro fertilisation), euthanasia (and life-support systems), and truth-telling in the patient-doctor relationship. In dealing with these themes, I will make very few editorial changes to the original 1988 seminar papers I researched and presented in the course. Now, several decades later, I recognise that each of these themes, and others, requires rigorous examination and critical engagement, especially in light of more recent and ongoing inquiry, research and critical analysis within the medical and health care systems. Hopefully, the content of these substacks offers a helpful introduction to some of the issues which remain important for us today.
My first and second substacks in the series on medical ethics may be accessed here: https://rogerarendse.substack.com/p/the-relationship-between-patient and https://rogerarendse.substack.com/p/procreation-the-value-of-the-human .
Euthanasia - a moral dilemma ahead
The moral responsibility to “prolong life and relieve suffering” (Smith 1970:123) is a valuable principle for human society. Underlying criteria for this principle, to a greater or lesser degree, is ‘reverence for life’ and ‘human compassion and love.’ At a deeper level is the belief that death is an enemy, and some or all suffering is either unnecessary or even inhumane.
An illustration of the above principle being ‘more easily’ applied is needed. For example, if a patient has an acute appendicitis, an operation would be both necessary and good to relieve the suffering caused, and prolong the life of the person by preventing the often fatal rupturing which would occur.
However, an ethical and moral dilemma is evident as is the case all too often today, when “preserving life and relieving pain are not two sides of the same coin which neatly complement each other; instead they present themselves as alternative courses of action which are often in conflict and occasionally mutually exclusive” (Smith 1970:123). For example, a doctor treating a patient with severe stomach cancer may have the responsibility of prolonging the patient’s life, but even the best medical treatment will not relieve the suffering except at the risk of shortening the patient’s life. Some may argue, justifiably, that this illustration is not relevant to the ‘euthanasia debate’ per se (Oosthuizen ed. 1978:14). However its relevance is clearer if there is at least some involvement of the doctor in shortening of the patient’s life, namely, through ‘passive (negative) or active (positive) euthanasia,’ or where patient consent is involved, namely, in ‘voluntary’ and even ‘compulsory’ euthanasia (ibid.: 28-29). Here some crucial questions emerge, for example:
Who decides when a person’s life is to be terminated?
Is death an enemy to be avoided at all costs?
What is the exact moment of death and which values determine the answer given?
What criteria are used to determine when/when not euthanasia is the right thing?
Who decides what the ethical-theological criteria in the debate ought to be?
This substack will seek to identify and briefly explore some of the ethical-theological criteria involved in the euthanasia debate and which seek to provide some answers to the above questions, and many more. I assume as a priority those ‘grey areas’ where ethical-moral dilemma arises in the doctor-patient relationship, and the extremes of ‘absolute prohibition’ and ‘absolute permission’ of euthanasia are ignored.
Some ethical-theological criteria involved in the euthanasia debate
An Anglican position
For the Anglican, some significant theological criteria in the debate would be:
(1) that death is not intrinsically negative (Oosthuizen ed. 1978:14);
(2) both doctor and patient should as far as possible enjoy maximum freedom in the choices he/she makes (ibid.: 13), and
(3) the rule of Christian agape should apply at all times.
A Roman Catholic position
The Roman Catholic view would endorse the Anglican position, but insist on the proverb: “Thou shalt not kill, yet should not strive officiously to keep alive” (Oosthuizen ed, 1978:29). This Catholic position is more essentialist in asserting that the value of a person’s life is determined more by what he/she is than by what he/she has or might be used for in society. (ibid.: 29). These criteria disallow ‘active’ and ‘compulsory’ euthanasia for two important reasons:
(1) the fear that human beings may begin to ‘play God’ who is held to have the prerogative in taking life, and
(2) the fear that its legislation would give too much freedom to the medical profession or State to determine the value of life, and the moment of death for different people (ibid.: 29).
‘Passive’ and ‘voluntary’ euthanasia are accepted with certain reservations through a primary appeal to criterion (2) above, and ‘respect for life’ as a gift from God. It permits the doctor’s responsibility to benefit the patient by allowing him/her to die well. For example, “a therapy which was only prolonging death in a hopeless case would be withdrawn, allowing the patient to die” (ibid.: 31). It also emphasises ‘patient autonomy’ by accepting as important his/her right to die with dignity.
But, with these criteria, one feels that ‘the protection of life’ and ‘preventing of harm’ for the patient holds sway over ‘patient autonomy’ because the meaning and value of life derived from strong Christian interpretations are the decisive factors. Therefore, the responsibility of the doctor co-operating with the process of dying:
(a) because the patient’s informed consent exists, or
(b) the patient’s inability to decide because ‘in extremis’ conditions prevail,
is considered more remote (Benatar ed. 1985:22).
An underlying bias in these Christian criteria just described, both for the protection of life and for limited passive euthanasia, is the firm belief in the death-resurrection of Jesus Christ, as the supreme value-standard for ‘life’ and who brings a fearlessness of ‘death.’ Consequently, there is the increasing danger that “professional hubris – the doctor’s pride and personal sense of well-being that come from conquering disease and death” (Smith 1970:126) – may become the motivating drive and not the criteria themselves.
A Jewish position
The above ‘Christian’ criteria reflect a particular biblical interpretation not accepted by many. For example, some Judaic criteria stress:
(1) “that life itself is neutral and whether it is good or evil will depend on the use to which we put life, or the degree to which we fulfil the expectations of our Creator” (Benatar ed. 1985:24), and
(2) all life, in its tiniest form or in its totality, must be respected as of infinite value and therefore, no “sanction of any deliberate action calculated to induce death” is allowed (ibid.: 25).
While Christians may agree that life is of infinite value, where the restricted conditions for passive euthanasia are present, many would hold that ‘death’ should not be avoided at all costs because it is not an ‘absolute negative’ as Judaism seems to suggest. Some Christians would also reject the underlying Judaic belief in the ‘innocence’ of human life as a determining factor in preventing the death of the patient.
An Islamic position
This viewpoint accepts the criterion “that life is a gift from God and man is its steward” (Benatar ed. 1985:30). But the stronger Islamic stress, more identical with Judaism than with Christianity, is that the ‘sanctity of human life is of greatest concern (Oosthuizen ed. 1978:53) and therefore, the primary criterion in the euthanasia debate. ‘Active’ and ‘compulsory’ euthanasia are cautiously accepted, especially where “the choice is limited between saving the life of a possible human vegetable and a patient whose survival is a certainty according to all medical progress” (ibid.: 55).
However, a double-standard applies in equating passive euthanasia in the case of ‘a human vegetable’ with that of ‘abortion of a child’ when the pregnant mother’s life is in danger (Benatar ed. 1985:54). On the one hand, all life is held to be of greatest importance and Allah alone ought to be the great leveller (ibid.: 53). But on the other hand, some ‘lives’ are deemed more valuable than others based mainly on medical decision-making. This may be an attempt at relevance in areas of ethical dilemma, though it reflects the fundamental problem where ethical-theological criteria founded on dogmatic religious grounds become inadequate in promoting or prohibiting particular medical practices.
A Buddhist position
The primary Buddhist criterion is that volition – “the ability of the person to choose and decide” (Oosthuizen ed. 1978:74-75) – is the essence of meaningful human existence. A person is considered dead when his/her volition is dead. This criterion for certifying when ‘death’ occurs is different from the “Brain Death standard established by the Harvard Medical School in 1968” (ibid.:77, see additional reading on this in the ‘references’ below). This criterion seems more precise and provides a more definite measurement in the euthanasia dilemma than many other theological criteria described above. Also, it is helpful in calling for a “new definition of death” (ibid.:78). But this Buddhist criterion and arguments do show a tendency towards irrationalism by relegating ‘religious grappling’ and ‘scientific empiricism’ to relative unimportance (ibid.: 72).
A Traditional African position
This perspective, by stressing that euthanasia of any form is ‘murder’ reflects a position similar to the ‘absolute prohibitionist’ view (Oosthuizen ed. 1978:60). But the difference is evident when one sees that this theological-ethical criterion stems from a belief in ‘Divinity’ as “all embracing and encompassing the totality of life” (Benatar ed. 1985:32). Therefore, to ‘take life’ or ‘allow dying’ is an affront to Divinity.
Two great challenges emerge from an African viewpoint:
Firstly, it highlights that the euthanasia dilemma is essentially of Western origin. That is, the criteria used often are derived not so much from ‘pure theology’ or ‘pure ethics,’ but rather from a Western value-system and a predominantly Judeo-Christian mindset.
Secondly, it urges Western tradition to take more seriously the caring for the suffering or dying before hastening to moral justification of euthanasia in any form.
Conclusion
In this substack (with origins in the 1988 post-graduate seminar paper on Euthanasia introduced at the outset), I have not sought to answer the many questions which arise in the euthanasia debate. Rather, I had the more modest desire to identify and briefly explore just some major theological-ethical criteria employed in this debate.
The reader is referred to the ‘Reference’ section below for further material which go deeper into some of the issues only touched on above. Several online studies and articles are easily available as well.
Reflection and Journalling Exercise
I offer these questions for further reflection and journalling:
Do the criteria we establish for euthanasia reflect an equal concern for all life?
Is Beauchamp right in saying that “depending on the circumstances…it is the justifying reasons which make the difference whether an action is right, not merely the kind of action it is (1979:191)?
Does the legalising of euthanasia, even in extreme cases, remove greater evils than it would cause (Oosthuizen ed. 1985:15)?
References & additional readings
Beauchamp, T.L. 1979. “A Reply to Rachelson Active and Passive Euthanasia” in W.L. Robinson ed., Medical Responsibility: Paternalism, Informed Consent, and Euthanasia. Washington: Humana
Benatar, S.R. (ed.) 1985. “Ethical and Moral Issues in Contemporary Medical Practice, Session 1, The definition of death, medical intervention and religious responses. Cape Town: UCT Printing Department.
Oosthuizen, G.C. et.al. 1978. Euthanasia, Human Sciences Research Council Publication, No. 65. Cape Town: OUP.
Smith, H.L. 1970. Ethics and the New Medicine. Nashville: Abington Press.
Additional readings:
Ebrahimi N. 2012 “The ethics of euthanasia.”
https://www.amsj.org/archives/2066
Goddard, A. 2021 “Ethics at the End of Life (Euthanasia and Assisted Suicide).”
Nguyen, D. 2019. “Evolution of the Criteria of ‘Brain Death’: A Critical Analysis Based on Scientific Realism and Christian Anthropology.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6880070/
Sulmasy, D.P. 2021 “Physician-Assisted Suicide and Euthanasia: Theological and Ethical Responses.”
https://academic.oup.com/cb/article/27/3/223/6456503
Thank you for reading this current series of substacks related to issues of medical ethics.
Should they be of interest to you and others, kindly consider sharing more widely.
In my final substack in this series, I will explore the question: ‘What does it mean to tell the truth in a doctor-patient relationship.’
Blessings!