The Catholic Church espouses a consistent ethic of life that requires the legal protection of all human life from conception to natural death. Thus Pope Francis wrote, in his 2018 Apostolic Exhortation Gaudete et Exsultate (“Rejoice and Be Glad”):

The other harmful ideological error is found in those who find suspect the social engagement of others, seeing it as superficial, worldly, secular, materialist, communist or populist. Or they relativize it, as if there are other more important matters, or the only thing that counts is one particular ethical issue or cause that they themselves defend. Our defence of the innocent unborn, for example, needs to be clear, firm and passionate, for at stake is the dignity of a human life, which is always sacred and demands love for each person, regardless of his or her stage of development. Equally sacred, however, are the lives of the poor, those already born, the destitute, the abandoned and the underprivileged, the vulnerable infirm and elderly exposed to covert euthanasia, the victims of human trafficking, new forms of slavery, and every form of rejection. We cannot uphold an ideal of holiness that would ignore injustice in a world where some revel, spend with abandon and live only for the latest consumer goods, even as others look on from afar, living their entire lives in abject poverty. (GE 101, emphasis added)

The Holy Father rejects the lopsided view found among some Catholics that in the political arena abortion is “the only thing that counts.” The lives of the unborn are sacred and should be protected by law, but this is equally true of the poor and underprivileged, the elderly, and victims of human trafficking; in a word, anyone who is marginalized. In my previous post I discussed how this applies even to people guilty of grave crimes, who should never under any circumstances be put to execution. Today I would like to discuss euthanasia and assisted suicide.

On September 22 the Congregation for the Doctrine of the Faith, with the specific approval of Pope Francis (meaning this is part of his ordinary Magisterium), published a letter spelling out the Church’s teachings and pastoral practices concerning euthanasia and assisted suicide. It is called Samaritanus Bonus (SB)—named for the Good Samaritan.

For its doctrinal basis, it draws heavily upon the 1980 CDF Declaration on Euthanasia, called Iura et Bona, as well as some allocutions given by Pius XII in the 1950’s. Doctrinally, there is very little that is new in this document; the basic doctrine remains the same as it was 40 years ago. Over the years, some very specific elements regarding particular, difficult points have been elaborated, and this document tries to put everything into an overall, coherent framework. As such, it will be the touchstone for future Catholic discussion of this topic for decades to come.

The document is divided into two halves. The first half (sections I-IV) lays out the Church’s general thinking on the issue, with connections to the main themes of Pope Francis’s papacy, specifically mercy. The title of the document means “The Good Samaritan” (Luke 10:25-37) and indicates that the Christian response to those who are seriously ill or dying must be to comfort them and be present with them, and never to “put them out of their misery” or hasten their death. Thus we see a strong emphasis on pastoral accompaniment of the sick and dying—just being “present” with them, to show them we care and that they are still part of our family and community—as well as resistance to the “throwaway culture” that sees people as economic producers, to be discarded as soon as they cease to be profitable.

People who are dying often feel they have become a burden to their families and thus ask for euthanasia or assisted suicide as a way to relieve their caregivers. For this reason, it is a moral imperative to make sure such people are not made to feel like a burden. We must actively affirm their intrinsic human worth and dignity. If we don’t do that, it will be our fault if they ask for assisted suicide or euthanasia.

The second half of the document (section V) presents the official teaching of the Church in detail. Only this section is numbered by paragraph for ease of reference.

The fundamental, bedrock teaching is given as follows:

Euthanasia is a crime against human life because, in this act, one chooses directly to cause the death of another innocent human being. (SB 1)

To put it in plain terms, God said, “Thou shalt not kill,” so euthanasia—the “mercy” killing of the sick—is wrong (same as with abortion).[1] This teaching is “definitive,” which means that it is not open to future revision or correction.[2] Most of what is said in papal documents—including the other parts of this letter in their specifics—is “ordinary Roman magisterium,” which means that it expects Catholics to accept it with “religious assent (obsequium) of intellect and will” (Lumen Gentium 25). What is being asserted here is that this particular teaching (euthanasia is wrong since it is direct killing) is of a higher level of authority; it is to be held definitively.[3]

How is that possible? Is the pope here making an ex-cathedra dogmatic definition that involves papal infallibility? No. Then did an ecumenical council address the issue of euthanasia and define this as a dogma? No again. Then how?

According to the teaching of the Church:

Although the individual bishops do not enjoy the prerogative of infallibility, they nevertheless proclaim Christ’s doctrine infallibly whenever, even though dispersed through the world, but still maintaining the bond of communion among themselves and with the successor of Peter, and authentically teaching matters of faith and morals, they are in agreement on one position as definitively to be held. (Ibid.)

So, the CDF is asserting that this is already the case, and has been the case for some time, with the teaching on euthanasia. The pope and the bishops in communion with him have been teaching, not as a provisional or preliminary judgment but definitively, that euthanasia is always wrong, ever since the question was first raised. No new authority is being added to this teaching by this letter. Rather, the CDF is merely re-affirming, on Francis’s authority as pope, that this was already a definitive, irreformable teaching of the Church (see SB 1, note 38). This foundational teaching is the only part of the document that is stated definitively; all the additional particulars, details, and specifics in the rest of the document are part of Pope Francis’s ordinary Magisterium.[4]

If you read through the document, you will see the related moral questions that come up. Most of these revolve around the fundamental distinction between what ethicists and moral theologians call “ordinary” or “proportionate” means of medical care and “extraordinary” or “disproportionate” means. While it is easy to say that “directly causing” someone’s death is wrong, this gets muddy during end-of-life discussions, both theoretically and practically.

For instance, some people may feel unnerved by “do not resuscitate” (DNR) orders, which instruct doctors and nurses not to perform CPR on certain sick people. In this case, it is clear that by not performing CPR you are not directly killing someone; you are merely letting them die (something you likely could not have stopped anyway, since CPR is usually unsuccessful). As such, this is obviously not euthanasia. It is morally permissible. In fact, it may be morally obligatory not to perform CPR on some people, if they are so weakened that, even if you could re-start their heart, you would inflict horrible damage and they would just die again soon after. Performing CPR in such a situation would be considered “extraordinary” or “disproportionate.”

But other cases are not nearly so clear-cut as DNRs. What does it mean to say that a medical treatment is “disproportionate”? It may be helpful to recall the distinction used in discussions of just war, which is also part of the Church’s teaching. Violence in self-defense or to protect the innocent may be justified only as a last resort and under certain conditions (such as declaration by legitimate authority and a reasonable chance of success). One of those conditions is proportionality. For example, let us assume (this is just an example) that Russia’s annexation of Crimea in 2014 was an unjust aggression against the people of Crimea. Nevertheless, it would have been disproportionate in the extreme if the U.S. had retaliated by dropping a nuclear bomb on Moscow! The response to injustice cannot be worse than the injustice itself.

In the same way, the cure cannot be worse than the disease. Imagine someone is dying of inoperable cancer, but a doctor says an experimental new drug might stave off the cancer for a couple weeks, though without any chance of a cure. Unfortunately, one of the side effects of the drug is that it puts the patient into continuous agony. This would, obviously, not be a proportionate response. It would be better—again, this is obvious to any rational person—to let the person die and not inflict this drug on them just so they can live a few extra days in agony. I am not a physician, so I will not attempt to provide real-world examples, but suffice it to say that situations like this are very common in end-of-life care. Usually, the doctors are the first to caution against using disproportionate means; they know too well the suffering people undergo and how pointless it is to try to extend someone’s life when they are dying. In this regard, the CDF document strongly warns against a refusal to accept natural death:

To precipitate death or delay it through “aggressive medical treatments” deprives death of its due dignity. Medicine today can artificially delay death, often without real benefit to the patient. When death is imminent, and without interruption of the normal care the patient requires in such cases, it is lawful according to science and conscience to renounce treatments that provide only a precarious or painful extension of life. (SB 2)

Because of the unfortunate rhetoric of our times, some Christians may be suspicious of doctors saying to “let them die,” thinking that maybe this is the “covert euthanasia” that we have been warned against. This is absolutely not the case; disproportionate care should not be pursued.

To deal with all the possible cases in which one may have to decide whether or not to pursue certain medical treatments that could be considered “disproportionate,” many people now prepare “advanced directives” that spell out in writing, in detail, what a person wants their doctors to do or to leave undone. Such directives are legitimate and good:

The renunciation of treatments that would only provide a precarious and painful prolongation of life can also mean respect for the will of the dying person as expressed in advanced directives for treatment, excluding however every act of a euthanistic or suicidal nature. (Ibid.)

We should follow the advance directives that people set forth; it is a question of both respect and ethics.

But what is this last part about “excluding every act of a euthanistic or suicidal nature”? In many countries it is possible to request that, under certain circumstances, you receive absolutely no care at all, even what the Church would consider to be “ordinary” and “proportionate.” When we are talking about certain surgeries, procedures, therapies, or drugs, this will be up to the judgment of the individual and the doctors. But the Church maintains strongly that there are certain basic modes of care that are essential to life. These are spelled out in the letter exactly: “hydration, nutrition, thermoregulation, proportionate respiratory support, and the other types of assistance needed to maintain bodily homeostasis and manage systemic and organic pain” (ibid.) Among these are hydration, nutrition, and proportionate respiratory support: water, food, and air.

Sick people are sometimes given nutrition through a feeding tube and hydration through an IV. The Church holds that such care is ordinary, even when it is administered artificially. It is part of our basic moral duty, like the Good Samaritan, to give food to the hungry and drink to the thirsty (cf. Matthew 25:35). In some cases, a dying person might ask—or God forbid be pressured to—have these taken away, which would expedite approaching death due to dehydration. Although some ethicists may argue that removing an IV or feeding tube is always merely ceasing “extraordinary” medical care and therefore not euthanistic, the Catholic magisterium disagrees. The reason for this disagreement is that feeding someone and giving them water is not a medical act as such (even when done by modern technology) but an aspect of basic human care:

Nutrition and hydration do not constitute medical therapy in a proper sense, which is intended to counteract the pathology that afflicts the patient. They are instead forms of obligatory care of the patient, representing both a primary clinical and an unavoidable human response to the sick person. Obligatory nutrition and hydration can at times be administered artificially,^[62] provided that it does not cause harm or intolerable suffering to the patient. (SB 3)

Notice, however, that this principle is qualified and not at all absolute: “provided that it does not cause harm or intolerable suffering.” If the means by which food and water is being given becomes harmful or causes suffering (beyond the ordinary discomfort of having an IV in)—and this will often be the case with people who are very ill—then you have reason to discontinue it. But to remove them in order to hasten their death is euthanistic, even if you are not directly killing them (by administering a fatal drug, for example).

There is a second qualification. Nutrition and hydration may be discontinued if the body can no longer benefit from them: “When the provision of nutrition and hydration no longer benefits the patient, because the patient’s organism either cannot absorb them or cannot metabolize them, their administration should be suspended” (ibid.). If the person is so close to death that their body cannot even accept food and water, then they should be removed. They are not providing care any longer. This portion of the letter cites an earlier CDF response to the U.S. bishops in 2007.[5] This shows how specific ethical questions arise in particular circumstances; end-of-life care is not cut-and-dried.

What about ventilation? Notice that the document uses the word “proportionate” before “respiratory support.” Putting someone on a ventilator is ordinary care in many instances of medical treatment. When someone is dying, however, it is often foreseen that the ventilator cannot ultimately save them; they would have to remain on it forever, and no one can live that way. A ventilator is very intrusive, not at all like an IV. In such cases, the ventilator becomes disproportionate and may be removed. This is, as I understand it, a common scenario, and some people may be worried that to unhook it is euthanistic. If a person at death’s door and the only thing keeping them going is the ventilator, it is morally permissible to remove it.[6]

The document repeats that it is legitimate and appropriate to discontinue such treatments when they cease to be proportionate: “In some cases, such measures can become disproportionate, because their administration is ineffective, or involves procedures that create an excessive burden with negative results that exceed any benefits to the patient” (SB 8). Thus, a feeding tube, for example, may be used for a long time, but then the patient takes a turn for the worse and it becomes burdensome and/or ineffective. At such time, it should be removed, even if doing so has the foreseen (but unintended) effect of hastening the person’s natural death.

Another point I would like to mention is sedation. Sometimes people in extreme pain at the end of life are sedated for their comfort. This may also hasten their death. This is acceptable provided the intention is good: to relive their discomfort (SB 7). If the intention is bad, i.e., you are doing it to make them die sooner, then it is evil; you are willing their death. But if you merely foresee, as an unintended consequence, that they will die sooner under sedation, that is fine. This is called the principle of “double effect”: a morally-neutral act (e.g., sedation) has a good effect (e.g., pain relief) and a bad effect (dying sooner). If you intend only the good effect (though you understand the bad effect will equally happen), then your action is morally good.

A couple of pastoral points are made near the end of the letter. Catholic hospitals and health systems must follow these Catholic moral principles. If they don’t, they may be told by ecclesiastical authority that they must remove “Catholic” from their name (ibid. 9). Catholic hospitals, it should be noted, have ethical boards made up of moral theologians, members of religious orders, and priests, that handle specific questions on these more difficult cases. Hopefully the examples I have provided in this post have shown how complicated these decisions can be, as, most of the time, the distinction between “ordinary” and “extraordinary” is a judgment call based on the patient’s changing condition and expressed wishes.

The letter also forbids, in cases where someone chooses assisted suicide or euthanasia, for Catholic priests or chaplains to give Last Rites to such people or remain present “until the euthanasia is performed,” since that “could be interpreted as approval of this action” (SB 11). Some have already argued the letter here violates Pope Francis’s own pastoral principle of accompaniment of sinners. But the letter indeed instructs priests to accompany these people and to remain with them, in part in case they change their mind. Only priests cannot give absolution and Holy Communion if the person still intends to commit a grave sin. This does not mean the person is judged to be guilty of mortal sin and damned to hell, since “in these cases the guilt of the individual may be reduced or completely absent” (Iura et Bona II, quoted in SB 11). The reason the chaplain or priest should not attend the act of euthanasia or suicide is that it gives the appearance of approval, which would create scandal. Note that the document does not say that such presence automatically constitutes approval, as though it were judging the intentions of priests or chaplains; it only says that it “could be interpreted” in this way and therefore could create scandal.

Although there is not much that can be called “new” in this document, it lays out in one place the Catholic ethical principles involved in end-of-life care. It of course rejects euthanasia, which is against the Church’s pro-life/social-justice teachings, but it also rejects aggressive medical interventions. We should not be so “pro-life” that we refuse to accept death. In fact, the spirituality of dying is crucial to Catholic spirituality. When the time has come, and even when ordinary care has become burdensome or ineffective, it is time to let the person die. We Christians believe that death has been defeated by Christ’s resurrection (1 Corinthians 15:54). At the end of his life, St. Francis welcomed “our Sister Bodily Death, from whose embrace no living person can escape. Woe to those who die in mortal sin! Happy those she finds doing your most holy will. The second death can do no harm to them.”[7]

Notes:

[1] Could this also apply to the death penalty? This definition says “innocent,” so it is not transferable to the death penalty. However, moral theologian (and Francis critic) E. Christian Bugger (“Capital Punishment is Intrinsically Wrong: A Reply to Feser and Bessette,” 10/22/17) has made a compelling argument that Church teaching is moving in the direction of affirming that any intentional killing of a human being is wrong. Violence in self-defense as a last resort is acceptable provided it is not your direct intention to kill the aggressor; you must intend only to render him harmless, even if you foresee with a high degree of probability his death as an unintended consequence (for example, because you threw a grenade at him). Pope Francis’s teaching lends strength to this viewpoint since he taught that the death penalty violates human dignity. However, strictly speaking, he did not define capital punishment as intrinsically wrong per se in the exact same way that abortion and euthanasia are.

[2] When we speak of a teaching being “definitive” and “irreformable,” this refers to the substance of the meaning of the teaching, not the exact, particular wording it is given in a particular historical moment. For example, the dogma of the Real Presence of Christ in the Eucharist is irreformable, but the Aristotelian terminology of “substance” and “accidents,” which derives from medieval philosophy, can be altered. Historically, the way certain dogmas have been formulated verbally has been modified to better express the intended meaning. In fact, according to Pope John XXIII, this was the primary purpose of Vatican II. Even in the meaning, some doctrinal development may occur, but for a definitive teaching, that development would not entail a reversal as it could with teachings that were not definitive or irreformable.

[3] Definitive teachings are called by theologians “definitive tenenda” (Latin for “to be held definitively”) or “material dogmas.” They are distinguished from “de fide credenda” (Latin for “to be believed on faith) or “formal dogmas.” Formal dogmas are the highest and would include things like the Holy Trinity. Issues that concern the natural, moral law, such as euthanasia, by their very nature cannot be de fide dogmas, since they are based on the natural law and not on divine revelation. There is no passage in the Bible about euthanasia.

[4] Some of those details may be connected to the fundamental doctrine by a logical necessity, in which case they could not be questioned without simultaneously questioning the definitive teaching from which they derive.

[5] CDF, Responses to certain questions of the United States Conference of Catholic Bishops concerning artificial nutrition and hydration (1 August 2007): Acta Apostolicae Sedis 99 (2007), 820.

[6] For more detail on this point, see Fr. Tadeusz Pacholczyk, “What About Ventilators?” The Catholic Spirit (6/13/12): https://thecatholicspirit.com/commentary/making-sense-out-of-bioethics/what-about-ventilators/

[7] St. Francis of Assisi, Canticle of the Sun, tr. Bill Barrett, http://www2.webster.edu/~barrettb/canticle.htm.

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