Theological Aspects of Euthanasia

THEOLOGICAL ASPECTS OF EUTHANASIA Anthony Fisher O.P.

in John Keown (ed.), Examining Euthanasia: Legal, Ethical and Clinical Perspectives. Cambridge: Cambridge University Press, 1995 [forthcoming] Catholic writers on euthanasia usually offer a largely philosophical position, drawing upon that 'common morality' which is shared by all civilized societies, and eschewing the specifically religious or confessional. This allows them the better to engage in debate in a pluralist society and reflects the fact that morality can, in principle, be recognized by any reasonable person of good will, undeflected by distracting emotion, prejudice or convention. But because of our capacity for misdirection, and because we believe that the human situation is only adequately and reliably illuminated by the life and teachings of Jesus Christ, Catholics naturally look to the Church's scriptures and tradition for guidance. Morality is thus matter not only for philosophy but for doctrine and theology. It is a guide to a life which both befits our human nature and reason, and responds to our divine calling (Finnis & Fisher, 1993). This essay seeks to complement the more philosophical ones in the present volume, by showing the specific contribution which Catholic theology has to offer.

1. The euthanasia of King Saul

The story of the death of Saul, the first king of Israel, is related in the books of Samuel. Saul was badly wounded in battle by a Philistine arrow. Afraid of being tortured and humiliated by his captors, he pleaded with his armour-bearer to kill him (1 Sam 31:1-4; 1 Chron 10:1-4).1 There are two versions of what happened next. According to the first, the man refused, so Saul committed suicide by falling on his own sword (1 Sam 31:5- 6; 1 Chron 10:4). In the other account a young Amelikite came upon the wounded Saul leaning on his spear, perhaps attempting suicide. Saul begged him, "Stand beside me and slay me, for anguish has seized me and yet my life still lingers." So the youth obliged (2 Sam 1:6-10) in what today we would call an act of voluntary euthanasia, assisted suicide or mercy- killing.

We might note a few points about this incident. First, to use our contemporary slogan, Saul was thought to be 'better off dead', or in current medico-legal parlance, death was 'in his best interests': in so far as these phrases can be given any coherent meaning at all, they mean that he might reasonably have hoped to die, to 'go to his fathers'. Secondly, every one else was, more or less, better off with Saul being dead: David certainly was. Thirdly, the Amelikite who slew Saul seems to have done so with the best of motives: he was trusted by Saul and did nothing furtively; he formally mourned Saul's death and brought the crown and a full account to David. And fourthly, as the lad reported, "I stood beside Saul and slew him, because I was sure that he could not live after he had fallen" or, to put it in a modern idiom, "I stood by him and actively helped him have a peaceful death because I was sure he was terminally ill". So Saul died at the hand of a merciful man, having asked for euthanasia, being terminally ill and in great suffering at the time.

Yet the undoubted conclusion of this story is that despite being done with the best will in the world, this was none the less a wicked act, deserving the severest of punishments.2 When the lad arrived to tell David the news, no doubt expecting jubilation and personal reward, David did not rejoice even though Saul had been a great 'burden', indeed an enemy; instead he immediately rent his clothes, wept and fasted in a ritual demonstration of non-complicity and mourning, and had the youth punished for having killed his friend and the Lord's anointed (2 Sam 1:11-27).

2. Choose life

The so-called 'sanctity of life' principle,3 like the rest of Catholic morality, rests upon two complementary sources: revelation (or faith, theology) and reason (or natural law, philosophy). The God of the Bible is a living God who communicates his life to all living creatures, above all to the pinnacle of his creation, human beings (Gen 2:7; Ps 104:29-30; Isa 45:9-13; Zech 12:1).4 Human beings are accorded great dignity, created uniquely as God's image and likeness, little less than gods themselves, intimately known by God, joined to him as in a marriage covenant, destined and oriented to him as their ultimate goal (Gen 1:26-31, 9:6; Job 12:10; Ps 8; Wis 2:23; Isa 57:16; Hos 2; Zech 12:1; 1 Cor 11:7; Eph 5; Rev 1:16; cf. Aquinas, S Th IIa IIæ 1-5). The Incarnation and Redemption further dignify human beings: the Son of God himself became human, and died to redeem all people and make them 'children of God'. I will return later to the significance of Christ's passion for our present issue. For now it is enough to note that in the Christian view of things, life is a trust given into our stewardship by God (CDF, 1980; , 1994: #2280); we are called to choose life not death, and the ways of life not of death; any killing demands justification and the taking of innocent human life is always contrary to God's law and to that trust (Gen 4:8-11; 9:1-6; Ex 20:13; 21:22-25; 23:7; Deut 5:17; 30:19; 2 Kings 8:12;15:16; Jer 7:30- 32;19:4; 26:141-15; Mt 19:18 etc.). As the Catholic Church has recently put it:

Scripture specifies the prohibition in the fifth commandment: 'Do not slay the innocent and the righteous' (Ex 23:7). The deliberate murder of an innocent person is gravely contrary to the dignity of the human being, to the golden rule and to the holiness of the Creator. The law forbidding it is univerally valid: it obliges each and everyone, always and everywhere. (Catechism, 1994:#2261)6

Even if motivated by 'mercy' or a concern for the 'best interests' of someone who is thought to be 'better off dead', no one should assume the rôle of the Author of Life and Death.7

In common with people of other religions and none, the Christian 'natural law' tradition teaches that human beings are of great and equal worth and ought to be respected by others and protected by society; life is a basic good of human beings, a reason for action, an aspect of their fulfilment, a good they share in common and part of their common good; human lives are of such intrinsic importance that no choice intentionally to bring about the death of an innocent8 person can be right.9 This sanctity of life principle has been much referred to in legal cases and most recently in the House of Lords Select Committee report on euthanasia. It is said to be deeply embedded in our law and ethics throughout the world, recognized in international human rights documents, and basic to our common morality. It has also informed medical ethics since at least as far back as Hippocrates: killing is amongst the ways in which healthcare workers may not deal with their patients. Thus classical medical ethics has held that physicians might not be called upon to act as public executioners (Emanuel, 1991, pp. 19-20). Likewise it has traditionally excluded both active and passive euthanasia. For these reasons the court and the General Medical Council held that Dr Nigel Cox had acted "wholly outside" and "contrary to" his duty as a doctor when he killed a patient even though (like King Saul) she was in severe pain and had asked to be killed.10 Most people regard killing someone arbitrarily, or simply for advantage or the convenience of others, as inconsistent with a recognition of that person's dignity and as obviously immoral. More difficult cases arise when a person asks to be killed, especially where that person is 'weary of life', or in great pain, or very dependent, or a strain on the financial and personal resources of others. Similarly when the person is living in a state of permanent unconsciousness: most people would sympathize with a family and doctors who hoped that such a patient would die sooner rather than later. The question is: should we hasten the death?

The theological answer to this seems to be a resounding no: 'you shall not kill'. But this is no mere superstitious taboo or perverse decree from on high. Rationally we must recognize that were we to say yes to medical killing we would have to abandon the sanctity of life principle: and that is exactly what the proponents of euthanasia always ultimately do.11 Thus some deny that there is anything about human beings which is especially or equally valuable or deserving of respect: rather, they require certain qualifications, such as colour, creed, age, lack of handicap, or (as is presently fashionable) consciousness.12 Others, aware of the dangers of this elitist and discriminatory move, argue instead that every person's right to life should be respected , but that in some situations it might legitimately be compromised to serve other important 'values' such as the supposed 'best interests' or 'well-being' of the patient or (more often) the interests of the bystanders. This in turn highlights the fact that essential to respect for the precept against killing and to the killing-letting die distinction of classical and Christian medical ethics is a high view of human dignity and equality, and of our moral responsibilities in acting and forbearing to act with respect to it.

3. The Agony in the Garden: Liberal autonomy -v- Thy will be done

Having reviewed some implications of the death of the first king of Israel, we might turn now to the story of the death of the last: the Passion of Jesus Christ. Here God like David will rend his clothes asunder at the news of the killing of the king, tearing the veil of the Temple from top to bottom. But there is more to be gleaned for the purpose of the present debate than the principle of the sanctity of life.

The story begins with the agony in the garden (Mt 26:36-46 ; Lk 22:39-46). Jesus, contemplating the full horror of his suffering and death, is 'scared to death', falls to the ground shaking, and sweats blood. There is no Stoicism here, no romanticizing of sickness and death. Jesus enters into the full horror of human suffering: the pain and torment, the loneliness and abandonment. And like any of us would, he prays that this cup be taken from him. Yet he finishes his prayer, not like Saul asking to be speared (indeed, Jesus will be dead before the centurion arrives with that relief), but with the daily prayer of the Christian: "Thy will be done" (Mt 26:39,42 ; cf. Mt 6:10 ). Even the prospect of humiliation, pain and death does not dispense him from his obedience to the Father, the will of God, the law of the Lord.

This brings us to a second issue in the euthanasia debate and the one which receives the most attention in the press and the liberal philosophical academy: personal freedom or autonomy. Christian faith as well as secular bioethics have always required respect not only for the life of persons but for their free will. But 'autonomy' is now often equated with absolute freedom of self-determination, as when the House of Lords Committee (1994:#234), in keeping with recent legal trends, declared: "We strongly endorse the right of the competent patient to refuse consent to medical treatment, ". This sounds very reasonable in our individualistic, consumer culture; but, from a Catholic perspective, it is a distorted view of human dignity and freedom. First, because few sick people fit the somewhat idealized picture of the freely choosing agent: as the BMA itself recognized, "even apparently clear patient requests for cessation of treatment sometimes stem from ambivalence or may be affected by an undiagnosed depressive illness which, if successfully treated, might affect the patient's attitude" (Lords, 1994:#45). The Lords themselves expressed concern about the extent to which the elderly, lonely, sick or distressed feel themselves subject to pressure, whether real or imagined (1994:#239).

Another problem with a one-sided stress on autonomy is that it is radically asocial, even anti-social: all that matters is that I get my own way. But we are social creatures and human freedom is always exercised within a web of relationships. Christ does not attempt to go to his Passion alone: he takes his best friends with him to the garden and asks them to watch and pray with him. We too have to respect others; we have to consider the implications of our choices for their lives and for the common good. If we want to be 'put out of our misery' someone else must be involved: so someone else's 'autonomy' is unavoidably affected. So too is the community, for as Donne put it "No man is an island, entire of itself: every man is a piece of the continent, a part of the main... Any man's death diminishes me, because I am involved in mankind."

The third problem with much autonomy talk is that it fails to situate human freedom within the range of opportunities and values which are the context of human choice. The flip-side of the freedom of the patient to consent or refuse treatment, for instance, is that patients must exercise this freedom reasonably, in pursuit of their own good health and with respect for the good of persons in community. Free will is not mere whimsy, as the Agony of Christ in the garden demonstrated so graphically: we are not free to do 'whatever we please' with our bodies, our lives, our opportunities. We have to take into account our calling from God, the intrinsic morality of our choices, and their self-constitutive effects: what they do to us, what they make us, what they say about us. In the face of decisions as momentous as are those over life and death, we should say with Christ "not my will, Father, but thy will be done".

4. Mary stood by the cross: the duty to care

Next in the Passion narrative comes the arrest, trial and execution of Jesus. It presents each of us with the challenge: how do I respond to the suffering and impending death of others? In the garden and the court we see Jesus abandoned by his disciples; on the other hand Simon of Cyrene helps carry the cross and Jesus' mother and friend wait by the foot of the cross— by his bedside, if you will. This points to another basic principle in this area: the duty to care for others. Negatively, this means we may not harm people or treat them negligently or with disrespect ('': first do not harm); positively, it refers to our 'Good Samaritan' duties to show kindness to others, especially the most needy, and to our special responsibilities towards dependant persons in our particular care.

Time and again the Scriptures and the Christian tradition call us generously to care for those in need: widow, orphan, alien, sick. Compassion expressed in engagement with people to alleviate their suffering was very much a part of Christ's own mission, and was the standard of judgment he offered: when you saw me hungry, thirsty, sick, imprisoned, in one of the least of these my brethren, did you help? (Mt 25:31-46). But such engagement is not the preserve of Judeo-Christian faith: it is a duty supported by documents ranging from the Koran to the International Covenant on Economic, Social and Cultural Rights. It is almost universally agreed that access to certain basic measures such as food, water, shelter, clothing, sanitation, basic medical and nursing care should be available to all out of respect for their human dignity.

In addition to these common humanitarian duties we all have towards each other, healthcare workers have a special duty to do no harm to, nor take any undue risks with, their patients, but rather to seek to promote the patient's health. The principle that medicine is (called in the textbooks 'medical beneficence and non-maleficence') excludes the use of medicine for other purposes such as social engineering, exploitative experimentation, mere profit maximisation etc. and has traditionally excluded euthanasia: killing cures no one, is not nursing care, not therapy. It is normally possible to relieve another's suffering, at least to some extent. There positive alternatives to euthanasia: good therapeutic and palliative care; the expert pain management for which the hospice movement is rightly celebrated; good counselling and chaplaincy; love and support of a thousand different kinds. We should not underestimate the possibilities here nor overestimate the difficulty of realizing those possibilities—both of which proponents of euthanasia are inclined to do.

On the other hand we must face the fact (as opponents of euthanasia sometimes fail to do) that these positive alternatives may not eliminate the suffering. There are some problems in life which have no morally and practically available 'solution'. Then comes the really hard loving: the loving of a family surrounding a comatose boy, of a husband whose wife's Alzheimer's disease means she no longer recognizes him, of siblings playing patiently with their profoundly handicapped brother, of a mother watching patiently at the foot of her dying son's cross. Sometimes the best we can do is to invest ourselves—our time, companionship, prayer and hope—in the suffering, the comatose and the dying. By so supporting these people we affirm that bodily life is not merely an instrumental good distinct from the human person, but basic to humanity; we meet our fundamental duty of respect and care for every human life however wounded or handicapped; and we express our love for a particular person, maintaining our human solidarity or communion with that person as best we can. This is a kind of respecting and loving which no one should pretend is easy. The temptation is always to look for a quick-fix, to do anything to make the problem go away; and if not, to desert, to join Peter and the boys fleeing from the scene, abandoning not just another human being but one to whom they had pledged their lives.

Pain and death, we know, will not be eliminated in this life. Suffering must be faced head-on, against the pervasive temptation to demand an immediate technological fix for every discomfort, and to marginalize those who suffer so that the rest can withdraw undisturbed. Faith recalls the profounder possibilities for good occasioned by illness and pain: for the sufferer, re-evaluation, conversion, growth in virtue, setting things right with God and others; for onlookers, compassion and selfless behaviour. The crucified God gives new significance to these redemptive possibilities in suffering; contemplation of the cross and uniting oneself with Christ's passion make possible greater endurance, assist in our redemption (e.g. Mt 27:34; Rom 8.17-18), and overcome temptations to a counterfeit mercy. We are promised the Holy Spirit to help us in our weakness (Rom 8:26). But death remains our last enemy and is cannot be tamed or befriended, only conquered by Christ (1 Cor 15:26). In the end as we humbly admit our incomprehension before these mysteries, we take confidence in the knowledge that Christ has gone before us through pain and death into new life, and in the hope that we will share with him an eternity without sickness or pain.13

In medical situations there are many opportunities to save life; there are likewise many ways to abandon people and even to kill them. I have argued elsewhere that active and passive euthanasia are morally equivalent, simply a matter of strategy, and I will not rehearse that argument here.14 Suffice it here to say that passive euthanasia—intentional killing by means of dehydration, starvation, failure to perform necessary operations or to give appropriate drugs—is far more common in hospitals than killing by more active means. Thus I am advised that infants with certain handicaps are less likely to survive hospitalisation today than they were a decade ago, despite advances in medicine. Two recent English cases of what was arguably passive euthanasia of older handicapped persons were those of Tony Bland and 'S'. Both young men were more or less permanently unconscious and their assisted feeding was discontinued on the basis (a) that this was in accord with responsible medical opinion, (b) continued tube-feeding (and by implication, continued living) were not in the patients' best interests, and (c) their continued feeding (and living) were not in other people's interests.15 One might argue that assisted feeding is an inappropriate 'treatment' for the persistently unconscious, and should be withdrawn, without intending their deaths.16 But in both these cases the was apparently to hasten the young men's deaths, to kill by omitting to care, and the courts approved. Most countries have had similar cases in recent years.

Medical abandonment and killing by deliberate neglect, sanctioned by gradual erosion of the common law and gradual change in medical practice, is the most likely way for euthanasia to become widespread. In many places there is already considerable lobbying for the legalization of 'benign neglect by physician' and this is well-supported by some medical professional bodies and judicial fiats. Once again we must face the fact that to allow such 'benign neglect' would be to compromise one of the most basic principles of ethics, both religious and secular, a principle common to society generally and (at least historically) to the healthcare professions in particular: the duty of care for others.

5. Did God kill Jesus? The limits to the duty of care

There are, of course, limits to the duty of care as here are to every positive duty. Catholic faith and common morality recognize that while one may never intentionally kill, one need not strive relentlessly to preserve the last vestiges of life. The sanctity of life principle does not require 'survival no matter what'. Indeed, a survival-at-any-cost approach may well be due to therapeutic obstinacy, a refusal to face up to the limitations of healthcare and to human mortality, a product of despair rather than respect for life. Death is always an evil, but not the greatest evil; for many people it is a merciful release, the natural end to a life-story well- written and, as believers claim, the door to eternal life.

At some point in most people's life death becomes, as it were, 'inevitable'. If there is an opportunity to do so, it is important to compose oneself to die well—a need which can be frustrated by too strenuous an effort to prolong life. While one should always value life as a gift, one may not be obliged to prolong it by means of highly intrusive or 'extraordinary' treatments. Care and respect for the dying often requires palliative and hospice care, and if this is to be applied it will be necessary for people to accept that death is near and that there is little more that human effort can properly do to postpone it. Thus traditional medical ethics and Catholic morality counsel against over-treatment as well as under-treatment, and allow that some treatments will be withheld or withdrawn for good therapeutic reasons: their continued use may be futile or they may impose such a burden (in terms of pain, indignity, disruption, confinement, risk, cost etc.) that those concerned judge it disproportionate to the benefit gained (e.g. , 1994:#2278; CDF, 1980; Lords, 1994:##240,252-253).

Jesus as he hung upon the cross cried out and he was offered pain- relief, an anaesthetic, vinegar (Mt 27:48 ). Christian tradition teaches that the taking of pain relief may be reasonable even if this has the foreseen side-effect of shortening life (CDF, 1980; , 1994: #2279). The same is true where treatments are withheld or withdrawn for good reasons. This is the so-called 'doctrine of double-effect'. Put simply it is this: when healthcare professionals do some otherwise good thing (give a pain-relieving drug, withhold or withdraw some treatment...) and death results earlier than it might otherwise have done, hastening death need not be why they chose such a course of action. Accelerating death is often no part of the healthcare worker's reason for such conduct; death may or may not be foreseen, but it is not intended; it belongs neither to her ultimate purpose, nor is it the means used to achieve that purpose.17 On the other hand, a healthcare professional might give a pain-relieving drug or fail to treat because she believes the patient would be 'better off dead', or that others would be better off were the patient dead, etc. In this case hastening the patient's death is certainly part or the whole of the reason for the healthcare worker's chosen conduct and the course of action is immoral. Thus the judgment that a treatment is too burdensome ('extraordinary') or that pain relief should be given is involve any arbitrary judgments of 'quality of life', 'best interests' or 'well-being' such that a person's life is judged to lack overall value.

When we ask about intentions we are getting to the heart of our moral character: who we are and what we are about. The difference between intending-and-causing and foreseeing-but-not-intending is not alwayseasy to discern, and people's intentions are often as confused as their motives are mixed. But for the most part what is intentional is not in doubt, and various questions and what-if tests can be used to clarify intentions. We do not hold that the martyrs committed suicide even though they foresaw their deaths would 'result from' talking the stands they did. Likewise with Jesus' death. Jesus could have evaded his captors yet again; God could have intervened and saved him. Yet God kept Jesus' executioners in being and grace sufficient to do their dastardly deed. Yet still we say: God did not kill Jesus; we killed Jesus. God's will in this was permissive only, as it is whenever we choose to do evil; he is never the active agent of evil. Likewise with double effect in our choices: there are often undesired side- effects from our morally reasonable choices which we permit but do not will, do not 'purpose'.18

6. Jesus is tried by the ideologies of our age

Finally, if we look back a little in our Passion narrative we will find Jesus tried by the ideologies of own age. First, there is Caiaphas, the model of consequentialist reasoning, who declares: "better that one man should die for the people..." (Jn 11:50; 18:1) just as some contemporary high priests of bioethics would make new exceptions to the precept against killing as a matter of 'mercy', 'best-interests' or for some 'greater social good'. Here common morality and its Catholic variant replies insistently: 'The end does not justify the means', 'Do not do evil that good may come'.19 Next there is Pilate who, though staring Truth in the face, shows himself the very model of modern liberal nihilism: "Truth: what is that?" (Jn 18:38). Many of the governors of our age are equally inclined to dodge difficult ethical questions, to pretend that medical ethics is all a matter of private opinion, so that all standards are 'up for grabs' as long as people are 'civil', 'kindly' and 'respectable'. To this common morality responds: of course we should seek by whatever means are morally and practically available to ease people's suffering. But beware: in hard cases sympathy and compassion will tempt us to compromise our basic norms and to fudge our laws. The temptation, one we all know in our moral lives, is to think that what is right is so complex and difficult and relative to each situation that we can allow just one, or a few, exceptions and still hold the line 'as a general rule'. But rational reflection and human experience suggest that the implications of such exceptions go far wider than the relief of hard cases.

Apart from the intrinsic evil of killing people, medical killing changes us individually, as healthcare professionals, and as a society. Even discounting the person killed, euthanasia is not 'victimless' because the person who carries it out is also significantly harmed in the process, as is the wider community. The healthcare professional's character will be very significantly shaped by killing a patient, however noble her motivation. Such an action will change her attitudes, dispositions, taboos. A healthcare worker who has decided that some patients may be killed has, however well-meaningly, seriously undermined in herself a disposition indispensable to the practice of good medicine: respect for the life and health of every patient. So too with any community. Ethically, psychologically and sociologically, euthanasia invites further extension of 'therapeutic killing', whether by the same healthcare worker or by others. Euthanasia also discourages alternative responses to suffering, such as research into cures and the provision of good palliative care and pain management.

There are many other problems with the euthanasia answer which I have no space to explore here: so I might just flag a few. How are we to interpret the plea of patients or by-standers for euthanasia? Is it really a plea for death or a plea for better pain-relief, better support, comfort and love? What effect will medical killing have on the doctor-patient relationship and medical ethics? How soon would licence for euthanasia become a duty to take part in it, and how soon would we slip from voluntary to non-voluntary euthanasia?20 There is also the spectre of the economic pressure, in a rapidly-aging society in which healthcare costs are escalating, to keep extending the occasions for medical killing as a cost- cutting measure. In all, the House of Lords Committee (1994:#238) was right to conclude that "these dangers are such that we believe any decriminalization of voluntary euthanasia would give rise to more, and more grave, problems than those it sought to address."

For all the polemics about 'well-being', 'dignity' and 'mercy' used both by the euthanasia movement and now even by our institutions, we can forget that dignity is not recognised by telling the old, infirm or comatose how undignified their condition is, or how they would be better off dead—as when judges called Tony Bland 'grotesquely alive', 'an object of pity', 'the living dead', called 'S' a mere body for whom starving to death would be 'no ill effect', and called some handicapped children 'cabbages'. For all the special pleading by the Caiaphases and Pilates of our age, well-being and mercy are not served by medical abandonment, by standing by while people starve to death or by intervening to kill them. The so-called 'mercy' killer adds the final rejection to the many already heaped upon the sick and dying by our community.21 Dignity in old age, handicap, unconsciousness, and suffering are above all recognized by our showing the infirm love and respect. Surely we can find more creative ways of responding to suffering than killing.

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ENDNOTES

My particular thanks to Fr Robert Ombres, O.P. who helped me with this piece.

1. Unlike Abimelech's armour-bearer who slew him at his request, lest he suffer the humiliation of death at the hands of a woman: Judges 9:50- 57. Other scriptural examples of suicide include: Saul's armour-bearer (1 Chron 10:5), Ahithophel (2 Sam 17:23), Zimri (1 Kings 16:18-19) and Judas (Mt 27:5; Acts 1:18).

2. A fuller treatment of responsibility and sin in this area would require consideration of the nature of conscience, and especially of the 'vexed' and the 'erroneous' conscience, and of the implications for responsibility of passions (such as overwhelming sympathy) and moral climate (such as upbringing in a pro-euthanasia society). See O'Rourke & Boyle, 1989:ch.2, who refer liberally to the teachings of Vatican II on the dignity of conscience; and Delhaye, 1968:36-99 on the scriptural and patristic sources that underlie the teachings on conscience found in Aquinas and in Vatican documents. The , 1994:#2282, notes that "grave psychological disturbances, anguish or grave fear of hardship, suffering or torture can diminish the responsibility of the one committing suicide." On the other hand it also insists (#2277) that killing in response to an error of judgment made in good faith is nonetheless objectively evil.

3. See Boyle, 1989; , 1994:## 2258-2283; Clouser, 1973; Donagan, 1977.

4. CDF, 1987: "Human life is sacred because from its beginning it involves the creative action of God and it remains for ever in a special relationship with the Creator, who is its sole end. God alone is the Lord of life from its beginning until its end: no one can under any circumstance claim for himself the right directly to destroy an innocent human being." (quoted also in , 1994:#2258). See also: Bailey, 1979; Sena, 1981.

5. CDF, 1974:#5: "Human life, even on this earth, is precious. Infused by the creator, life is again taken back by him (cf. Gen 2:7; Wis l5:11). It remains under his protection: man's blood cries out to him (cf. Gen 4:10) and he will demand an account of it, 'for in the image of God man was made' (Gen 9:5-6). The commandment of God is formal: 'You shall not kill' (Ex 20:13). Life is at the same time a gift and a responsibility. It is received as a 'talent' (cf. Mt 25:14-30); it must be put to proper use." Vatican Council II, 1965: #27: "The varieties of crime are numerous. They include all offenses against life itself, such as murder (), genocide, abortion, euthanasia and suicide... all these and the like are criminal: they poison civilization; they debase the perpetrators even more than the victims; and they offend against the honour of the Creator".

6. Likewise CDF, 1980: "Human life is the basis of all goods, and is the necessary source and condition of every human activity and of all society... No 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... It is necessary to state firmly once more that nothing and no one can in any way permit the killing of an innocent human being, whether a foetus or an embryo, an infant or an adult, an old person or one suffering from an incurable disease, or a person who is dying." I have not been able to review here the development of the tradition behind this teaching through the fathers, the scholastics and the papal magisterium. CDF, 1980 includes references to some of Pius XII's teaching in this area; O'Rourke & Boyle, 1989: 111-115 include some texts from John Paul II. An example of a recent episcopal statement is English Bishops, 1993.

7. , 1994:#2277: "an act or omision which, of itself or by intention, causes death in order to eliminate suffering constitutes a murder gravely contrary to the dignity of the human person and to the respect due to the living God, his Creator. The error of judgment into which one can fall in good faith does not change the nature of this murderous act, which must always be forbidden and excluded."

8. I qualify the prohibition of intentionally killing with 'innocent' here in line with common morality which has traditionally recognized a right (and sometimes a duty) to render unjust aggressors unable to inflict harm, even with lethal force. This might include justifiable capital punishment and war, but obviously not euthanasia. On the justification for the 'exceptions' see Fisher, 1993a and , 1994:#2263- 2267,2321 and the sources in each. Hereafter I use the terms person, victim and life presuming (or at least allowing) the traditional qualification 'innocent'.

9. cf. Ashley & O'Rourke, 1989:ch. 13; Donagan, 1977; Finnis, 1980; Grisez, 1983:chs.5, 7,9; Grisez, 1993:ch.8; Grisez & Boyle, 1979; May, 1977:ch.6; Pollard, 1989.

10. (1992) (Unreported; Ognall J in the Winchester Crown Court, 18 September 1992); likewise: [1957] Crim LR 365; (, 5 November 1981; Farquhason J). In many places there is considerable lobbying for the legalization of "physician aid- in-dying" as practised in Holland.

11. My thought in this area has been much influenced by Gormally 1993a,b,1994.

12. This was the crucial qualification in the mind of the judges in [1993] 2 WLR 322 (''), so much so that they were sometimes unclear about whether Anthony Bland was really a living human being. Similar reasoning is to be found in the works of Warnock, 1992 and Dworkin, 1993, among others, and has been very effectively rebutted in Gormally, 1994.

13. For some reflections on suffering and death as they are understood in the Judeo-Christian tradition see: Ashley & O'Rourke, 1989:47-49,197- 199; Casey, 1991:chs. 4,5; Cassidy, 1994; , 1994:##988- 1019,1500-10,1521; Dougherty, 1982; Hellwig, 1985; John Paul II, 1985; Soelle, 1975.

14. See Fisher, 1993c and Finnis, 1980:176-77,195 ( Glover, 1977 and so many since), on where action and omission are morally different and where they are morally equivalent. The law recognizes the equivalence of action and omission in some cases. Thus people have been convicted for killing by omission: (1838) 8 C & P 425; (1850) 4 Cox CC 455; (1874) 13 Cox CC 75; [1893] 1 QB 450; (1918) 13 Cr App Rep 134; [1977] QB 354; (Judge Geoffrey Grigson in Old Bailey, 7 March 1994); Lord Keith at 362, Lord Browne-Wilkinson at 383 and Lord Mustill at 394; Smith & Hogan, (6th ed, 1988) at 52.

15. , regarding which see: Finnis, 1993 and Fisher, 1993a,b. (unreported Court of Appeal 14 January 1994), regarding which see: Fisher, 1994 and Stone, 1994.

16. Though I have argued to the contrary in Fisher, 1993a. A good case could certainly have been made, however, for not intervening surgically and with aggressive antibiotics. It is mysterious that such intervention occurred in the last year of Anthony Bland's life, when it might have been withheld without ethical or legal difficulties.

17. 'Intentional' here is a term of ethical art. It refers to what one does, identified by reference to one's chosen purpose in acting and the means which are chosen precisely because of their relevance to that project. When death is foreseen but not intended, its causation does not feature among the reasons one has for acting; it is unintended, perhaps even regretted. Some people treat intentional and foreseen-but- unintended causation as morally equivalent, but this would mean one could never build roads, engage in high-risk sports, perform high-risk surgery, give analgesics for pain control which might reduce life span, withhold treatment, and so on, while being opposed to killing.

18. Scriptural examples of just acts involving risk of death to the actor are the deaths of Samson (Judges 16:23-31) and Eleazar (1 Macc 6:43- 46). For helpful accounts of intention and double effect: Anscombe, 1963; Aquinas, IIa IIæ 8-21, 79; Boyle, 1980; , 1994:##1737,2283; May, 1978.

19. See Finnis & Fisher, 1993 and sources therein for reasons why any comparison which hopes to guide moral judgment by an overall 'weighing' of the goods and evils at stake in morally significant options is always made by feelings, not rational commensuration, and will ultimately be only rationalization.

20. Lords, 1994:#238: "we do not think it possible to set secure limits on voluntary euthanasia... it would not be possible to frame adequate safeguards against non-voluntary euthanasia if voluntary euthanasia were to be legalised...Moreover to create an exception to the general prohibition on intentional killing would inevitably open the way to its further erosion whether by design, by inadvertence, or by the human tendency to test the limits of any regulation."

21. Lords, 1994:#239: "We believe that the message which society sends to vulnerable and disadvantaged people should not, however obliquely, encourage them to seek death, but should assure them of our care and support in life."