From Euthanasia to Aid in Dying

As we have studied extensively in the historical introduction to our course, the Catholic tradition (exemplified especially by St. Alphonsus Ligouri) has consistently emphasized that in certain circumstances Catholics may licitly refuse life-prolonging treatment: HOWEVER this is in no sense the equivalent of suicide. This principle has been reiterated in modern times in Jura et Bona and Evangelium Vitae

- It is always permissible to make do with the normal means that medicine can offer.	- Semper licet satis habere communia remedia, quae ars medica suppeditare potest.
Therefore ONE CANNOT IMPOSE ON ANYONE the obligation to have recourse to a technique which is already in use but which	Quapropter nemini obligatio imponenda est genus curationis adhibendi quod, etsi in usu iam est,
[1] carries a risk or [2] is burdensome.	adhuc tamen non caret periculo vel nimis est onerosum.
Such a refusal is not the equivalent of suicide; on the contrary, it should be considered as	Quae remedii recusatio comparanda non est cum suicidio verius habenda est vel
[1] an acceptance of the human condition, or	simplex acceptatio condicionis humanae;
[2] a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or	vel cura vitandi laboriosum rnedicae artis apparatum cui tamen par sperandorum effectuum utilitas non respondet;
[3] a desire not to impose excessive expense on the family or the community.	vel denique voluntas onus nimis grave familiaee aut communitati non imponendi.
- WHEN INEVITABLE DEATH is IMMINENT in spite of the means used, it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted. In such circumstances the doctor has no reason to reproach himself with failing to help the person in danger.	- Imminente morte, quae remediis adhibitis nullo modes impediri potest, licet ex conscientia consilium inire curationibus renuntiandi, quae nonnisi precariam et doloris plenam. vitae dilationem afferre valent, haud intermissis tamen ordinariis curis, quae in similibus casibus aegroto debentur. Tune^, causa non est cur medicus animi angore afficiatur, quasi alicui, qui in periculo versaretur, auxilium negaverit.

65. Certainly there is a moral obligation to care for oneself and to allow oneself to be cared for, but this duty must take account of concrete circumstances.	Officium certissime adest morale ut quis se curet curetque se curandum; quod tamen officium metiendum est secundum concreta rerum adiuneta:
It needs to be determined whether the means of treatment available are objectively proportionate to the prospects for improvement.	in re namque nata necesse est diiudicare conveniantne therapeutica instrumenta ad manus aliquando melioris condicionis ipsis exspectationibus.
To forego extraordinary or disproportionate means is not the equivalent of suicide or euthanasia;	Haud vero tantum valet consiliorum extraordinariorum vel nimiorum reiectio quam voluntaria mors vel euthanasia;
it rather expresses acceptance of the human condition in the face of death	consensum potius illa declarat cum humano statu ante mortem

Such a situation can threaten the already fragile equilibrium of an individual’s personal and family life, with the result that, on the one hand, the sick person, despite the help of increasingly effective medical and social assistance, risks feeling overwhelmed by his or her own frailty;	Porro pertemptatur aequabilitas nonnumquam iam incerta vitae privatae ac familiaris, ut hinc aegrotus, etsi efficacioribus usque subsidiis providentiae medicae et socialis sustentatus, periculo obiciatur ne opprimi sese sua fragilitate sentiat;
and on the other hand, those close to the sick person can be moved by an understandable even if misplaced compassion.	illinc vero in iis qui adfectu quodam inter se iunguntur valere possit pietatis sensus qui facile intellegitur quamvis perperam comprehendatur.
All this is aggravated by a cultural climate which fails to perceive any meaning or value in suffering, but rather considers suffering the epitome of evil, to be eliminated at all costs. This is especially the case in the absence of a religious outlook which could help to provide a positive understanding of the mystery of suffering.	Quodam praeterea morum habitu haec omnia exacerbantur, qui nullam in dolore significationem aut virtutem detegit, quin immo ut malum praecipuum censet quovis pretio propulsandum; quod turn rnaxime accidit cum religiosa desideratur rerum aestimatio qua iuvetur quis ut in bonam partem doloris arcanum interpretetur.
On a more general level, there exists in contemporary culture a certain Promethean attitude which leads people to think that they can control life and death by taking the decisions about them into their own hands.	Attamen in toto cultus humani prospectu aliquid certe efficit ratio quaedam Promethei animi super homine qui sibi persuadet posse sic sese vita morteque potiri, cum de illis decernat,
What really happens in this case is that the individual is overcome and crushed by a death deprived of any prospect of meaning or hope.	dum revera devincitur ac deprimitur interitu irreparabiliter clauso ante omnem sentiendi exspectationem omnemque spem.
We see a tragic expression of all this in the spread of euthanasia - disguised and surreptitious, or practised openly and even legally.	Calamitosam horum sensuum omnium testificationem in late prolata deprehendimus euthanasia, tecta quidem et prorepente aut quae palam peragitur vel lure etiam ipso permittitur.
As well as for reasons of a misguided pity at the sight of the patient’s suffering, euthanasia is sometimes justified by the utilitarian motive of avoiding costs which bring no return and which weigh heavily on society.	Haec vero, praeter quam ex adserta quadam misericordia de dolore alicuius patientis hominis, defenditur interdum ex certae utilitatis aestimatione, ob quam nempe nimia pro societate impendia infructuosa declinari debeant.
Thus it is proposed to eliminate:	Itaque suadetur ut
[1] malformed babies,	nati deformes,
[2] the severely handicapped,	graviter praepediti
[3] the disabled,	et invalidi,
[4] the elderly, especially when they are not self-sufficient,	senes potissimum sibi providere non valentes,
[5] and the terminally ill.	necnon insanabiliter aegrotantes tollantur.
Nor can we remain silent in the face of other more furtive, but no less serious and real, forms of euthanasia. These could occur for example when, in order to increase the availability of organs for transplants, organs are removed without respecting objective and adequate criteria which verify the death of the donor.	Neque silere hoc loco nos par est aliis de tectioribus, nihilo tarnen minus veris et gravibus, euthanasiae modis. Accidere illi possunt cum, verbi gratia, ad organorum eopiam transplantandorum augendam, ipsa auferuntur organa minime quidem normis obiectivis congruisque servatis de certa donatoris morte.

Important tactics in the political struggle to legitimize and legalize euthanasia include the following:

1. Denial that it is, in fact, euthanasia. Supporters of euthanasia insist that the phrase “physician-assisted suicide” is pejorative and offensive, and that it should, instead, be described as “aid in dying”. Thus in 2003 one of the most powerful pro-euthanasia lobbies changed its name from “The Hemlock Society”, to “End Of Life Choices;” and in 2004 it merged with a similar organization called “Compassion in Dying”. In 2005 the new entity reinvented itself as “Compassion and Choices.”

2. Denial that there is any significant moral distinction between withdrawing disproportionate therapy and intentionally hastening or causing death: i.e. the principle of double effect is meaningless.

In his detailed and insightful article “Euthanasia: Historical, Ethical, and Empiric Perspectives” Ezekiel J. Emanuel, MD, PhD, inadvertently facilitated the latter approach by describing the withdrawal of inappropriate treatment as “passive” or “indirect” euthanasia. (Arch Intern Med. 1994;154(17):1890-1901. He made it clear in his article that he considered aggressive pain management and withdrawal of disproportionate therapy to be moral and acceptable: however, his categories have been cited by later authors as implying the moral equivalence between these actions (and the principle of double-effect that underlies them) and “other forms of euthanasia”

His definitions, which have been quoted in numerous similarly-oriented articles are as follows:

Term	Definition
[1] Voluntary active euthanasia	Intentionally administering medications or other interventions to cause the patient’s death at the patient’s explicit request and with full informed consent
[2] Involuntary active euthanasia	Intentionally administering medications or other interventions to cause a patient’s death when the patient was competent but without the patient’s explicit request and/or full informed consent (e.g. patient was not asked)
[3] Nonvoluntary active euthanasia	Intentionally administering medications or other interventions to cause a patient’s death when the patient was incompetent and mentally incapable of explicitly requesting it (e.g. patient is in a coma)
[4] Terminating life-sustaining treatments (passive euthanasia)	Withholding or withdrawing life-sustaining medical treatments from the patient to let him or her die
[5] Indirect euthanasia	Administering narcotics or other medications to relieve pain with incidental consequence of causing sufficient respiratory depression to result in a patient’s death
[6] Physician-assisted suicide	A physician providing medications or other interventions to a patient with understanding that the patient intends to use them to commit suicide

Despite the fact that Physician-Assisted Suicide and euthanasia have only been legally available to Dutch citizens since 2002, both have been tolerated within Dutch society for several decades (Griffiths, Weyers & Adams, 2008). Within Europe, Switzerland, Belgium and Luxembourg currently allow PAS. Switzerland is the only country in the world where the act of assisted dying can be conducted by someone who is not a physician. Furthermore, non-Swiss persons are permitted to take advantage of the Swiss law, with individuals travelling to Switzerland to die by assisted means.

Oregon is another interesting jurisdiction, as in this US state since 1997, a terminally-ill person who has been diagnosed as having less than six months left of life may request and receive a prescription from a physician or nurse practitioner and they are then at liberty to take or not take the medication to end their life. In these Oregonian cases, the ill person may be assisted by a family member or home care nurse or anyone else to commit suicide. If the person becomes too advanced in their illness to pick up and/or swallow the medication, the pills could be crushed and introduced via a feeding tube or other means by their caregivers.

Within the US, several other states also allow assisted suicide. Washington (2009) allows assisted suicide under a Death With Dignity (DWD) law. In 2009, the Supreme Court in the state of Montana also clarified the law’s position that neither state law nor public policy prevented the prescribing of lethal drugs to terminally-ill patients who want to end their lives (O’Reilly, 2010). Several other states are currently considering their own DWD laws (i. e. Vermont, Massachusetts, New York, Pennsylvania, and Hawaii). Similarly, in Canada, a Supreme Court judge ruled in mid-2012 that persons who cannot commit suicide themselves are disadvantaged by the current law that prevents assisted death practices from occurring openly (Wilson et al., in press).

Quebec, a Canadian province, has also studied the matter of assisted death and completed a report in late 2011 that recommends both assisted suicide and euthanasia should be practiced in the province for those who wish it, and also that palliative care should be more accessible and available to those who need it

“Assisted or Hastened Death: The Healthcare Practitioner’s Dilemma” (Global Journal of Health Science; Vol. 4, No. 6; 2012. ISSN 1916-9736 E-ISSN 1916-9744. Published by Canadian Center of Science and Education)

In 2008 an Interview published by the Swiss News Service, Swissinfo, invited Dr Jerôme Sobel, the president of Exit, a pro-euthanasia organization that facilitates assisted suicide, to describe his “work”:

swissinfo: In Switzerland there are two assisted suicide organisations: Exit and Dignitas. What’s the difference between them?

Dr. Sobel: The main difference is that, as revealed by the two cases that occurred last week [Craig Ewert and Daniel James], Dignitas agrees to assist foreign citizens. Also, with Dignitas there is a financial cost for the patient, unlike with Exit.

The members of our association, which has existed since 1982 and involves around 70,000 people, pay an annual fee of SFr30 ($27).

swissinfo: And what are Exit’s conditions?

Dr. Sobel: The main one is that we look at requests from Swiss citizens or foreigners who are permanent residents in Switzerland. For one reason: we only have a few assistants and too many requests.

swissinfo: What does an assistant do?

Dr. Sobel: They are the ones responsible for following the patient. They are volunteers who study each case, meet the person’s relatives and friends and, when the time comes, provide the patient with the lethal solution.

swissinfo: What happens following a request for assisted suicide?

Dr. Sobel: There is a grace period between the request for assisted suicide and the moment it’s actually carried out.

The patient has time to resolve any unsettled matters and say goodbye to family members and friends. Then, from the moment the final date is set, we ask the patient for confirmation that this is indeed their wish.

swissinfo: And what happens next?

Dr. Sobel: The patient is given a solution with about ten grams of sodium pentobarbital mixed with a fruit juice that they must be able to drink on their own.

If not, this would be considered euthanasia and not assisted suicide. It’s a subtle but very important nuance.

This Webpage was created for a workshop held at Saint Andrew's Abbey, Valyermo, California in 2002....x.... ’ “”.



_1. AN ESSENTIAL DISTINCTION: Physician-Assisted Suicide versus Refusal of Disproportionate Treatment



_2. DENYING the DISTINCTION: Euphemisms for Euthanasia Physician teaching students



_3. EUTHANASIA in EUROPE and in THE U.S.A.