Perhaps you have been asked or thought about what you would do if your friend and fellow soldier—wounded in battle and left suffering enormously and near death but without any available medical treatment— begged you to end his life to ease his suffering. This is a horrible situation to imagine, one that, thankfully, few if any of us will ever encounter. But situations where we must decide how to best act toward loved ones who are suffering and near death are sadly not at all uncommon. And given the advanced state of medical technology, the difficulty of end-of-life decision making has only been exacerbated. Decisions today are not only whether to simply care for suffering people until they die, but whether or not to purposely end their lives to ease their suffering. We must also on occasion choose whether or not to use treatments that may themselves hasten the death of a patient. Or we are faced with decisions about whether or not to withhold or remove treatments that appear useless or burdensome, but that nonetheless may keep a person alive.

What all of these decisions have in common is that they impact the length of the patient’s life. One common response of bewildered people facing such complicated decisions is, “don’t play God!” Nothing seems more God-like than influencing the time of someone’s death. But if the aim of those who warn us “don’t play God,” is avoiding any impact on the length of someone’s life, then this advice is misguided. Our decisions in many unavoidable situations truly will impact the length of patients’ lives. Should any available treatment be undertaken by a patient, no matter her condition, or can patients opt out of certain treatments? And what of treatments that are undertaken to better or prolong one’s life but sadly and unintentionally end up causing death, as regularly happens in the medical world? Are we to stop performing surgeries so as to not play God?

If playing God means making medical decisions that impact the length of someone’s life, then doing so is unavoidable. The real task (for the person of faith) is to “play with, rather than against, God.” Of course, that is likely what people who say “don’t play God” mean. But the rub, if you will, is determining which decisions go against God’s will and which do not. In other words, how can we make end-of-life decisions well, or virtuously? Given the complexities of this arena, answering this question requires far more than a simplistic slogan about playing God.

In fact, when we begin to sort out exactly what sorts of decisions constitute playing for or against God, we find that the relevant features of such decisions—intention, patient condition, usefulness of available treatment, and the like—are not accessible only to people of faith. They pertain to an innerworldly activity (end-of-life decision-making) and thus are accessible to people of any or no religious conviction. They are the stuff, if you will, of natural law. This does not mean, of course, that theological commitments do not shape our understanding of such situations and actions; as the previous chapter on sexuality illustrates, they certainly do. As will be seen in the first section of this chapter, faith certainly impacts one’s understanding of the meaning (if any) of suffering, or of the extent to which we are willing to live in a manner dependent upon others. The Christian tradition also has specific norms relevant to the issue of euthanasia (such as the sixth commandment, “thou shall not kill”), norms which believers have consistently interpreted as bearing on the case of euthanasia. In short, faith matters for how one does natural-law reasoning concerning innerworldly activities such as end-of-life decision making. Nonetheless, the aspects of euthanasia that make such an act contrary to Christian commitments (i.e., which make it playing against God, or a violation of the commandment) are accessible to persons of any or no religious commitment, and may therefore be discussed accordingly. Hence, this chapter will proceed largely without direct reference to faith commitments, largely because even when discussed in reference to such commitments, the issue of euthanasia demands precision and analysis on matters that do not depend on those commitments.

The purpose of this chapter is to examine how virtuous end-of-life decisions are made in general, and whether or not euthanasia can ever be one such decision in particular. Euthanasia is an enormously large topic. Thorough treatment of this issue would require a book, or books. Therefore, many important facets are left unaddressed here. These include statistics on how and when people do actually die, data from places like Oregon and the Netherlands where forms of euthanasia are legal, discussions of how legalized euthanasia would and does impact the practice of the medical profession, and the impact the legalization of euthanasia would have on vulnerable populations, such as the poor and uninsured.

This chapter takes on three more specific goals. The first section addresses the reasons why people might welcome death, in order to determine whether or when such a stance can be virtuous. The argument of this section is that there are indeed times where it is virtuous to embrace death, although not always. The second section, recognizing that there are a plenitude of ways one might welcome death, defines euthanasia more precisely so as to delineate what exactly is, or should be, meant by euthanasia in debates over this issue. Euthanasia is most properly defined as the intentional termination of a patient’s life in order to end suffering. The third and final section examines in detail, in light of section one’s claim that it may indeed be virtuous at times to welcome death, whether euthanasia as defined in the second section is ever a virtuous response to end-of-life suffering. It concludes that though death may be virtuously welcomed at times, and though genuinely prudent decisions may indeed cause the death of a patient, the intentional ending of a patient’s life—even out of the well-meaning desire to end suffering—is never a virtuous act.

Later sections examine more closely the immediate task of this chapter: the definition and morality of euthanasia. But before entering that debate, it would help us to understand better why people would ever desire to die, and whether or not—or when—such a desire can be virtuous. The purpose of doing this is twofold. First, a more careful analysis of people’s reasons for seeking death may reveal that this is a bad decision, and realizing why will hopefully lead more people in such situations not to seek death. This has obvious ramifications for the perceived need for euthanasia. But the second reason is to point out that at times it is indeed reasonable to be willing to surrender one’s life and welcome death. Simplistic slogans such as “do not play God!” can make it seem as if death is to be avoided at all possible costs. Even among people who oppose euthanasia, however, this need not be the case. It is hoped that this section will enable people to decide more prudently when it is and is not virtuous to embrace death.

In a beautiful article entitled, “The Pressures to Die: Re-conceiving the Shape of Christian Life in the Face of Physician-Assisted Suicide,” David Cloutier considers why people seek physician-assisted suicide, which, as ex-plained below, is one form of euthanasia.David Cloutier, “The Pressures to Die: Reconceiving the Shape of Christian Life in the Face of Physician-Assisted Suicide,” in Growing Old in Christ, ed. Stanley Hauerwas, Carole Bailey Stoneking, Keith G. Meador, and David Cloutier (Grand Rapids: Eerdmans, 2003), 247–66. He focuses on two main reasons:the avoidance of suffering and a desire not to be dependent on others. Cloutier does not dismiss these reasons, but rather hopes to present a more accurate understanding of suffering and dependency so they do not unduly lead people to seek euthanasia. His work is used in this section to help people better decide when and when not to embrace death.

As to the avoidance of suffering, it must be clearly stated that pain and suffering are not good. If they were, then we would purposely impose them on ourselves and others. If they were, we would always be against treatments (such as palliative care or pain relief) whose aim is to diminish pain and suffering. In fact, if pain and suffering were simply good, it is difficult to see how medicine as a profession would make sense. In ways described further below, some people (particularly Christians) do see the possibility of meaning in suffering. Nonetheless, it must be made perfectly clear that saying this is not the same as saying that pain and suffering are good.

The reason why this is important to state at the outset is that, at times, opponents of euthanasia will refer to the meaning and value of suffering to counter euthanasia supporters who cite real suffering as a reason to purposely end the lives of some patients. The problem with responding with arguments based on the value of suffering is that such arguments so often fail to include resources for saying why we do seek to alleviate suffering at times, only to espouse the value of suffering suddenly when it comes to euthanasia. Opponents of euthanasia must be careful in discussing suffering not to make claims that would render unintelligible, even immoral, standard and uncontested medical practices aimed at alleviating pain and suffering. In response to arguments praising the value of suffering in debates over euthanasia, one could respond, “so you are against pain relievers such as aspirin?” People almost never are, and so it is necessary to situate claims about the possibility of meaningful suffering more carefully.

People who cite the value of suffering generally mean two things, both of which are indeed true. First, they mean that suffering can have a purpose. This is something that all people grant. Certain surgical recoveries, physical therapies, burn treatments, and the like all involve significant (at times brutal) pain and suffering. But these are endured for the sake of what is gained by the treatment. If “avoid pain and suffering at all costs” were the appropriate norm governing such situations, we would not do certain virtuous things that we currently do. Therefore, while pain and suffering are not simply good, neither are they to be avoided at all costs.

Cloutier refers to this type of suffering as educative suffering. It is endured because the suffering is directly related to—usually the path to—some good that is obtained through the suffering. It is encapsulated by the phrase “no pain, no gain.” The meaning of such suffering is easier to grasp, and caregivers can comfort people in these predicaments by reminding them of the light at the end of the tunnel of their pain and suffering. But Cloutier rightly acknowledges that not all suffering is so clearly educative, or a direct path to some good, such as health. Sometimes it seems there is no purpose to suffering. Think of how cruel it would be to say to a terminally ill and suffering patient at the end of life, “no pain, no gain.” In certain situations of pain and suffering, there is no obvious gain, or light at the end of the tunnel, which is achieved through a path of suffering.

It is in precisely these situations that supporters of euthanasia assume that such suffering is meaningless, and see no reason to continue such suffering. Indeed, even the Catholic church recognizes that it is completely permissible to seek the alleviation of pain and suffering through palliative care. Yet there is a second reason why people may recognize value even in suffering that is not immediately directed to some good purpose. Here is one place where things are seen differently from the perspective of the Christian story. Without glorifying (or certainly mandating) suffering, Cloutier rightly describes how Christians have always found something potentially meaningful and redemptive in suffering. This is a particularly common theme in the letters of St. Paul, who says things like: “when I am weak, then I am strong” (2 Cor. 12:10), and “I rejoice in my sufferings for your sake” (Col. 1:24). What does this mean? Do Christians seek suffering or claim it is simply good?For an extraordinarily powerful reflection on the meaning of suffering, see John Paul II’s apostolic letter, Salvifici Dolores (Encyclical Letter, 1984).

Absolutely not. Yet a foundational theme of the Christian story is that suffering and death are not the last word. Ultimately, God’s power, mercy, and love overcome death and suffering. In fact, sometimes in times of suffering we are able to experience more fully the faithfulness and power of God’s saving presence, as it can penetrate even the darkest of hours and bring light in the most unexpected moments. This is of course what happened on Easter Sunday after the horror of Good Friday. As it concerns end-of-life decisions, this is not some wishful thought that perhaps the suffering patient will be cured by a miracle—though of course all things are possible with God. Rather, it is a radical laying down of one’s life in trust that God is provident, good, and faithful. Christians have consistently reported throughout history that such occasions can be powerful experiences of God’s presence and grace. Perhaps there is a renewal of the patient’s faith. Perhaps there is overdue reconciliation between members of the family. Perhaps the patient’s fortitude in facing death has a transformative effect on the patient’s loved ones. What is common to all such experiences is that the patient’s suffering itself is not inherently tied to some gain, and yet some meaning is found in this time of suffering. Hence Cloutier calls it redemptive suffering.Cloutier, “The Pressures to Die.”

Christianity, centered as it is on the story of Good Friday to Easter Sunday, has unique resources to recognize the potential meaningfulness of suffering— again, without idealizing it. So it is less surprising when Christians refuse to avoid suffering at all costs in end-of-life decision making. Yet it should be noted that the refusal to avoid suffering at all costs is not a position particular to Christianity. Even those who support euthanasia in situations of seemingly pointless suffering generally do not advocate involuntary euthanasia for suffering, conscious patients. In other words, their respect for the decision of a patient who does not choose to seek euthanasia in such a situation reveals that they prioritize patient autonomy before the avoidance of such suffering. So even they see the possibility of meaning in such suffering—even if it is simply the meaning of respecting patient autonomy. The simple point here is that though pain and suffering are not good in themselves, and though palliative care to treat them should be readily available, it is not therefore the case that suffering should be avoided at all costs. The avoidance of suffering rightly looms large in end-of-life decision making, but it should not be solely determinative.

The second main reason offered by Cloutier as to why people seek euthanasia is to avoid being dependent on others. How often do we hear aging parents tell their children, “I do not want to be a burden on you”? Anyone who has known or cared for someone at the end of life knows that it can indeed be an enormous burden in terms of time, energy, money, and the displacement of other worthy endeavors. Both for the patient and the caregiver, there is an understandable sense that this is a bad situation to be avoided. But again the question is, at what cost? Without idealizing or glorifying dependency, is it really something to be avoided at all costs, even the cost of ending the dependent terminally ill patient’s life?

Cloutier observes that in such an autonomy-minded culture as America today, it is easy to regard dependence as simply a bad thing to be avoided. But he suggests that end-of-life dependence can recall to us just how dependent the good life is for every one of us. We obviously begin life completely dependent, as we often end it. But even as mature adults we depend on those around us: such as family, friends, spouses, and children. We depend on colleagues at work, and fellow citizens who serve the common good of our town or nation. We depend economically on others. Of course others depend on us in so many of these ways. The point here is not to equate these types of dependence with that experienced at the end of life, when even basic bodily functions may require assistance. The point is that being burdened by others, and in turn burdening them, may be a more accurate assessment of our everyday life than our perceived autonomy, such that end-of-life caregiving, while surely distinctive in its often high demands, is only quantitatively, not qualitatively, different from the dependence at work throughout our entire lives.

There is something true and understandable about the common sentiment to want to avoid being a burden to others. It is indeed a good thing that adults are generally able to provide for and take care of themselves, and pursue activities other than the constant and demanding care of a loved one at the end of life. There are occasions when the mental, physical, emotional, and economic cost of caring for a loved one should influence end-of-life decision making. But just as there can be meaning in suffering, so too can there be meaning and value in dependence. Our understandable fear of placing enormous strain on others should not lead us too quickly to avoid placing any burden, even significant burden, on those around us. Our mutual dependence, as Cloutier calls it, is not simply something to be endured, but indeed is constitutive of living a good life. In other words, we are all better off to the extent that we allow ourselves to be burdens to and burdened by others.

One of the best illustrations of mutual dependence advocated by Cloutier can be seen in New York City immediately after September 11th. As a native New Yorker with many friends and family still there, I was regaled in the days after the attacks, not only with stories of the suffering endured, but also with stories of how New Yorkers were changed for a time in how they tended to those around them. The dramatic stories of heroism are well known. But even in ordinary situations people seemed more attentive to others, even strangers. People checked on elderly neighbors. They actually spoke and listened to people at work who previously were simply inhabitants of the same floor in a building. On subways, where every New Yorker knows the standard practice is to shut up and avoid eye contact, people not only spoke to, but actually checked in on, those around them who seemed to be suffering. People were more aware—sadly for too short a time—of their interconnectedness to those around them, and saw clearly that they depended on, and were dependent on, others. Such stories are common in areas ravaged by disaster, including natural disasters. Why does it take such horrible and dramatic events to remind us of our dependency? When these disruptions of our normal way of living occur, are they really reminders of what is true about our mutual dependency, even when we ignore it in more everyday life?

As noted above, this brief discussion of two common things that prompt people to seek euthanasia has been undertaken for two reasons. First, though each reason makes a visceral appeal to our sympathies toward people who wish to end their own lives, neither suffering nor dependency is something that should be avoided at all costs. This is not to glorify or idealize either. But if we fearfully run from each unreflectively, we will be making bad decisions at the end of life whether we seek euthanasia or not. A more accurate understanding of these facets of life enables us to make better end-of-life decisions.

But the second reason these topics are addressed here is to acknowledge that quality-of-life judgments can and must be made during end-of-life decision making. And at times, given the enormous suffering experienced, the burden of ongoing treatment on all involved, and an advanced incurable condition, it may indeed be appropriate to decide to stop fighting the disease and devote one’s self to preparing to die. Opponents of euthanasia who deny this do so at their peril, and alienate people whose openness to euthanasia may really be driven by the simple recognition that at times it is appropriate to welcome death. This is a judgment about quality of life, and may indeed mean one dies sooner than if one had continued to fight. But given the advanced state of medical technology today, such judgments at times are necessary.

People of faith cannot avoid making such judgments. Of course, how they are made can vary. They can be made well or poorly. Cloutier’s argument about suffering and being a burden means that people can too quickly seek death by wanting to avoid suffering at all costs, or by failing to recognize the proper role of dependency in a good life. But that such judgments are made is unavoidable. What might be good reasons to change one’s stance from preserving life to welcoming death? The Catholic church’s Declaration on Euthanasia mentions several considerations for such a decision: “the reasonable wishes of the patient and the patient’s family”; “the advice of doctors who are specially competent in the matter”; “a wish to avoid the application of a medical procedure disproportionate to the results that can be expected”; “inevitable death is imminent in spite of the means used”; and, “a desire not to impose excessive expense on the family or the community.”Declaration on Euthanasia (Sacred Congregation for the Doctrine of the Faith, 1980), iv. Of course, reasons are given that may prompt a patient to continue to fight on, such as the desire to unite oneself “with the sufferings of Christ crucified” or to “show generosity at the service of humanity” by assisting in experimental treatments.Ibid., iii–iv.

Unfortunately, there is no precise measure available to precisely determine in all cases when it is best to decide to stop fighting for life and welcome death. There are clear ways the decision can be made well or poorly, but an accurate appraisal of a particular situation is necessary to best determine what to do on that occasion. There are even occasions when it could be virtuous to either fight on or cease to fight for life; both decisions could be virtuous, depending on the desires of the patient. What is needed here, obviously, is the virtue prudence. What is the best guard to ensure we are being truly prudent in our decision making? It is no guarantee, but a readily available guard is the possession of other virtues. Who are the brave, just, and temperate people in the family who can be relied upon to see clearly how to act well in the challenging situation at hand? Are factors in the decision being weighed properly, or are cowardice, greed, anger, or other vices warping how people are making decisions? Saying this is a matter of prudence is not of course to say that any conceivable decision made is a good one. But it is to say that one can, given circumstances that are sadly not uncommon, make a virtuous decision to welcome death.

We have gone a long way toward recognizing some of the concerns that prompt people to seek euthanasia. It is recognized here both that we do indeed make quality-of-life judgments at the end of life, and that it may be virtuous—even, or perhaps especially, on Christian terms—to no longer fight to live. We are now ready to address the core question of this chapter. Granting a genuinely virtuous decision has been made to no longer fight to live but rather to welcome death, can euthanasia be a virtuous way to act at such a time? The next section attempts to define euthanasia, and the final section offers an extensive treatment of the morality of euthanasia.

One of the biggest obstacles hindering fruitful discussion of the morality of euthanasia is the difficulty of defining acts of euthanasia. The term “euthanasia” is derived from the Greek, and literally means “good death.” But that is far too vague a definition, since there are plenty of good deaths that no one would label euthanasia. More commonly people think of euthanasia in the context of actions deliberately taken that lead to the death of a patient who is suffering and near the end of life. The death is good because it means an end to the patient’s suffering. But again, this is far from a definition since “actions deliberately taken” is so vague. Thus, the task of this section is to arrive at a definition of euthanasia.

There are many different ways to distinguish different actions taken at the end of a patient’s life. Of course, the main purpose of such distinctions is to say what acts are good and which are bad. So the task of describing different end of life actions is intricately intertwined with discussion of the morality of such acts. This section begins by surveying different ways people have distinguished end-of-life actions. The purpose is to show how they are all inadequate ways of defining euthanasia, save one.

One common way to describe end-of-life decisions is by the active/passive distinction. Some people may say, “I am against active euthanasia but am OK with passive euthanasia.” I can actually tell what they probably mean when they say this, but the “active/passive” distinction they offer to differentiate good from bad acts is problematic, for two reasons. First, it evacuates any meaning of the term euthanasia itself. If euthanasia can be bad if active, but good if passive, what does the word itself mean? It seems merely to signify a neutral occasion when a suffering patient dies, or some sort of decision that impacts the end of life. The real work of determining what is right and wrong is done by the terms “active” and “passive.” Yet this is inaccurate. We do not use the term euthanasia simply to refer to times a suffering patient dies.

Second, these two terms active and passive cannot rise to the occasion of distinguishing good and bad acts. Active euthanasia means something like a suffering patient dying sooner because of some action taken by a caregiver. And passive euthanasia means a patient dying sooner because of a decision by a caregiver (e.g., doctors, nurses, family, or friends) not to take action. But this simply does not work in distinguishing good and bad acts. Sometimes we choose to take actions that in fact lead to the quicker death of a suffering patient, and no one would call this euthanasia. Think, for instance, of surgery for a patient suffering a heart condition. Every surgeon knows there is a risk of a patient dying on the table. Yet knowing this, surgeons still take action, and on occasion actively hasten the death of their patients. But, of course, no one would call this euthanasia. Conversely, there are occasions when we would blame someone for being passive and not helping a suffering patient to live. The point is, euthanasia does not simply signify a neutral situation made good or bad depending on whether or not someone acts or not. First of all, that is not the way we use the term euthanasia; it means more than the death of a suffering patient. Second, the terms active and passive do not adequately distinguish good from bad end-of-life decisions. This is a confusing way of describing decisions at the end of life, and really should be dropped altogether.

Sometimes people distinguish good from bad acts at the end of life by observing the cause of death of the patient. They may say something like, “It is OK to let people die naturally, but we should not cause their death unnaturally.” Here what is offered to distinguish good from bad acts is not whether or not the caregiver acts (active/passive) but, rather, what is the cause of death—is it the disease or the caregiver or, as some say, is it natural or unnatural? We may of course be able to guess what sorts of situations such people are trying to distinguish, but again, the “cause of death” distinction is not an adequate way to consistently differentiate good acts from bad at the end of life. For instance, as the heart surgery example above illustrates, every medical practitioner knows that, on occasion, medical treatment itself may cause the death of a patient. These are not natural deaths. And, conversely, someone may die naturally, but from a completely preventable condition that should have been treated. Therefore, the cause of death is another ultimately ineffective way to distinguish good from bad acts surrounding end-of-life decisions.

Other distinctions are also used to help sort out good and bad acts at the end of life. Some emphasize the importance of consent, and say that if a patient consents to something it is OK, but it is not OK if there is no consent. Surely consent is crucial, but is it really true that whatever the patient wants and consents to is virtuous? We may not blame suffering people for their requests in such states, because there may be duress. But should we honor the request of anyone who gives their consent to have their life ended? Surely not. One last distinction people occasionally offer is based upon who causes death. The claim is usually that a patient causing his own death is OK, but it should not be caused by others. But again this does not work. We surely do not praise any occasion when someone causes their own death. Conversely, if there are occasions where it would in fact be better to end the patient’s life, why shouldn’t the patient be given assistance in doing so, if needed? To not do so (assuming it was truly the best thing for the patient) seems an injustice to the patient.

Each of the above distinctions tells us something. But the problem with each is that it is unable to serve the role of a consistent rule with which to judge good acts from bad. Often we hear the above terminology used, and we know enough from the context to fill in the rest of the story. So the distinctions may suffice on those occasions. But the problem comes in trying to use them in contested situations where their inadequacy quickly becomes clear. Thus the claim here is certainly not that one is morally blameworthy for using these distinctions. Rather, it is that each is ultimately inadequate in defining euthanasia and determining what actions surrounding end-of-life decisions are good and bad.

Where does that leave us? There is one remaining way both to define euthanasia and sort out good from bad actions during end-of-life decision making, and unsurprisingly, given the concept’s importance in this book, it is intention. What defines the act of euthanasia is the intent to end the life of a patient, out of a merciful desire to end the patient’s suffering. As the Declaration on Euthanasia states, euthanasia is “an action or omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated.”Ibid., ii. Note the prominence of intention in this definition. Something is euthanasia if there is an intention that the person die in order that suffering be eliminated. Given this way of speaking, euthanasia can be labeled morally wrong and/or illegal without the need for additional qualifiers (like active or passive). Of course, some people do not think euthanasia, even understood as the intentional ending of a patient’s life to ease suffering, is morally wrong or should be illegal, but that is a question for the third section of this chapter. The point here is that the definition of euthanasia as an intentional ending of a life (vs. simply action or inaction that does lead to the end of a patient’s life) more accurately and consistently distinguishes the type of action to which people refer when they use terms like active vs. passive or natural vs. unnatural.

Observe how this way of defining euthanasia makes sense of all the cases cited above. It works better than the active/passive distinction because euthanasia has a meaning that is not dependent on additional signifiers (active or passive) for moral evaluation. It also explains why the heart surgeon who actively ends her patient’s life does not commit euthanasia: she did not intend to end the patient’s life (but rather intended to heal the patient). Finally, it explains how certain passive occasions can be morally wrong, namely, if one purposely chooses not to act in order that someone die. In other words, intention can drive inaction as well as action.

See also how this way of defining euthanasia helps explain what people likely mean when they say, “it is OK to let someone die naturally but not to cause their death.” They generally do not precisely mean it is bad to cause the patient’s death, but rather that it is wrong to intend the patient’s death. Again, that is why treatments that do cause death unintentionally are not euthanasia. Conversely, by saying “it is OK to let someone die naturally,” they are not praising every occasion where a disease ends a patient’s life. Rather, they mean that an intentional decision not to keep treating someone, knowing this means they likely will die of their disease, is not the same as intending to kill someone. That is why the words “let die” are used.

Thus, for the purposes of this chapter euthanasia should be understood as an intentional act. This is how the term euthanasia is understood in Catholic church documents. Yet, note that this is also how euthanasia is best understood, given the current state of law in the United States. Currently, in the United States it is illegal to intentionally end a patient’s life, even if that is done to ease their suffering (one exception is treated below). It is not, of course, illegal to cause a patient’s death, as evidenced by surgical deaths or other decisions to treat or not treat that may lead unintentionally to a patient’s death. Whether or how intending death is different from causing death is a question addressed in detail in the next section. The point is raised here simply to give further credence and support to a definition of euthanasia based on intention, and to point out that this view of euthanasia is not particular to the Catholic church, or based solely on religious reasoning.

Of course, even if all were to agree that this is the best way to define euthanasia, the issue of whether or not it can be virtuous or should be legal is very much alive. In fact, the one exception to the above claim about euthanasia being illegal in the United States is found in the state of Oregon, where physician-assisted suicide is currently legal. Physician-assisted suicide (PAS) is when a patient requests a dosage of lethal pills from his physician to be taken with the intention of ending his own life. This is clearly one form of euthanasia, since the intent of both patient and doctor is that the patient ends his own life, with the doctor’s “assistance,” in order to end his suffering. There are certain conditions that must be met (incurable condition, suffering, imminent death), and more than one physician must attest to this condition. So the law permits only one form of euthanasia (namely, PAS), and only in certain conditions. It is noteworthy here, both as an exception to the general legal prohibition of euthanasia in the nation, and as another example of how euthanasia—even if legalized—is most properly understood on the basis of intention.

The first section’s discussion of end-of-life decisions is perhaps the most important practically: guiding people’s prudential judgments about when to continue the fight to preserve life, and when to end the fight and await death. But though we have touched upon the reasons driving people to seek euthanasia, we have not yet addressed the core issue in the debate over euthanasia: how to carry out that judgment. In this section of the chapter, let us grant that a genuinely prudent decision has been made by a person with his family that it is indeed time to end the fight. Echoing the words of St. Paul, this person may say, “I have competed well; I have finished the race; I have kept the faith. From now on the crown of righteousness awaits me” (2 Tim. 4:7–8). Due to an incurable condition, great suffering, and an imminent demise, the task at hand is no longer to prolong life but rather to vigilantly await the end of life, and even welcome death.

In what ways can one virtuously await death? The word “await” connotes a passivity. But we know from above that concrete decisions must be made to stop certain treatments, such as to forego certain new types of treatment, or to give painkillers that may impact the length of one’s life. It is not enough to say, “just await death.” Given the current state of medical technology, a patient’s length of life will indeed be influenced by our choices. The real question is how to choose well. And more specifically for this section of the chapter, are there some choices that are never virtuous? Euthanasia has been defined in the previous section as an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated. Can such an act ever be virtuous?

This section treats this question in three parts. First, it addresses the question of whether or not there really is any difference between intending the death of a patient vs. acting in a manner that hastens or causes that death, even though it is not intended. The second section grants that there is such a difference, and then explores whether there may yet be rare occasions when intending the death of the patient is virtuous. The third section examines the particularly challenging question of how to categorize different types of treatment to determine whether or not their removal necessarily constitutes an intent to end a patient’s life. This section concludes that intending the death of a patient is a further step than unintentionally causing a patient’s death, or withholding or removing life-sustaining treatments. Not only is intending the patient’s death (i.e., euthanasia) a further step, but it is also never virtuous, even when done out of mercy and even when a prudential decision has been made that the time has passed to continue to fight to prolong life.

Intention vs. Foreseen Consequences: Any Real Difference?

One of the main rationales given for the legalization of, or moral permissibility of, euthanasia is that we are in fact already acting in ways that bring about the end of life for people who are at the end of life and suffering greatly. So far this chapter has tried to demonstrate that this is indeed the case. The virtuous person cannot simply not act or decide not to play God; rather, she must act prudently in such situations, since her decisions will indeed impact the length of the patient’s life (her own or a loved one’s). Yet this section demonstrates that there is still a crucial difference between intending something and simply bringing it about. It is the former that characterizes euthanasia, and enables both the Catholic church and current U.S. law (PAS in Oregon excepted) to disallow it, even while allowing other acts that bring about the end of patients’ lives.

Consider a case that prompts euthanasia supporters to make the claim that we are already purposely ending people’s lives. It requires a word about palliative care, which is treatment for pain given to patients, and especially important at the end of life for those whose conditions entail great suffering. One of the common medical protocols for palliative care is the use of morphine or other opiate drugs to relieve pain. One characteristic of such drugs is that they build tolerance. That is, once one begins taking them, going forward more of the same drug is needed to achieve the same pain-relieving effect. Therefore, incremental increases in dosage are given to patients who are prescribed opiates like morphine for palliative care. However, though the body can endure a high dosage of such drugs if increased incrementally, the body’s tolerance for such drugs is not unlimited. In other words, eventually the dose needed to relieve pain can be high enough that it is the drug itself, and not the existing medical condition, that causes the death of the patient, often through respiratory failure.

The question is, if a patient is prescribed such drugs for pain relief, and the drug itself actually ends the patient’s life, has the patient’s life been intentionally ended? It is tempting to think yes. After all, the caregivers voluntarily gave the morphine. Furthermore, although it is generally not possible to know exactly when one has crossed the line and given a specific dose that will cause death, it is indeed the case that the caregivers know that causing the patient’s death is a possibility. Therefore, in this case there is a voluntary action (giving high doses of morphine) that has foreseen consequences. In other words, the caregiver knows that death may result from her treatment. Has the caregiver intentionally ended the patient’s life? Though some argue this is the case, careful attention to intentionality using the doctrine of double effect reveals otherwise.

Recall the doctrine of double effect from chapter 8. It helps us determine whether a particular course of action is virtuous or not, when good and bad effects both seem to follow no matter what one does. In this case, a caregiver gives pain relief, which is a good effect. But the pain reliever may hasten the end of the patient’s life, which is a bad effect. Alternatively, the caregiver can refrain from giving the pain relief, which has the bad effect of greater suffering for the patient even while it has the good effect of not hastening the patient’s death. This is a classic case of double effect. Is it permissible to give the pain relief?

There are three conditions of the doctrine of double effect.Recall from chapter 8 that most classic formulations of the doctrine of double effect contain four conditions. The first of the four is omitted here, since it seems superfluous. The first condition asks whether there is a good intent. In this case the intent is to relieve pain, and so the answer is yes. But couldn’t the caregiver’s intent really be to end the patient’s life? This question requires two answers. First, if the caregiver’s ultimate goal is the death of the patient rather than the pain relief of the patient (which is hopefully achieved without ending life, even though it may indeed end the patient’s life), then that malicious goal does indeed make the act bad. Second, recall that an intention is a principle that guides action. It is what gives a specific act its meaning, gives shape to the particular act done. If the intent really is to relieve pain, we should expect the patient to be given only the increase in dosage that is needed to secure pain relief. If a very large dose is given initially, someone can say the intent is to relieve pain, but the shape of the act reveals otherwise. The intent was really to end the patient’s life, since that is the only meaning that can explain the act of giving a suddenly high dose of morphine.

The second condition of double effect asks whether the evil effect is willed in itself, or is the means to the good effect. Again, if the goal of the act is to end the patient’s life, the act is bad. But that need not be the goal here. Indeed, most caregivers see their patients living on with relieved pain and consider their act to have achieved its purpose. And clearly the good effect (pain relief) is not achieved by means of the bad effect (death). Condition two is met.

Condition three concerns proportionality and asks whether the goodness of the good effect outweighs the badness of the bad effect. To determine this, we need to go back to the considerations of the sort addressed in the first section of this chapter: status of illness, prognosis, degree of suffering, toll on family, and so on. We granted, for this section, that such a situation indeed exists. What would be an example of a situation that did not meet this requirement? Imagine you were in a horrible automobile accident, and severely burned, requiring months of burn treatment that should ultimately be successful but will be excruciatingly painful. You are a young married person with small children. You are in horrible pain. Surely pain relief is in order. But in this case, should we risk giving pain relief that may ultimately cause your death (even if that is not the intent), when you will most likely recover, have many years to live, and have a family that awaits you? In this case the good of pain relief does not outweigh the possible bad effect of causing your death.

To euthanasia supporters it seems that we are already willing to voluntarily perform pain-relieving acts with the foreseen consequence of causing death. Therefore, there is no difference between incremental palliative care and, say, injecting a patient with potassium chloride which ends the patient’s life and thus his suffering. But the doctrine of double effect reveals the different inten-tionality of this latter act. Let us grant that condition three, on proportionality, is indeed met in the case at hand, and the ending of suffering by an injection of potassium chloride would indeed outweigh the bad effect of the patient’s death, given all the circumstances. What of the first two conditions? As to the first, what is the intent of the act? Recall, an intention is not a vague longterm goal but rather a principle that shapes a particular action. If the particular act (or object) under consideration is an injection of potassium chloride, the only goal that can be driving that immediate act is the death of the patient. That is what potassium chloride does in a person’s bloodstream. Thus, the intent is to end the patient’s life. Unlike the caregiver providing morphine, who would consider her purpose achieved if the patient lived on with his pain relieved, the one administering potassium chloride would consider her purpose achieved only if the patient died. Of course, that patient would no longer be suffering, since he would be dead. But that leads us to condition two.

Even if we were to grant that the goal (not the intent, which is more immediate) of the injection of potassium chloride were to ease suffering, the evil effect (death) is desired in itself, and indeed is the means to the good effect of cessation of suffering. It is by a cessation of living that suffering is ended. Condition two of the doctrine of double effect is thus not met. Therefore, injecting a patient with a deadly agent such as potassium chloride, in order to relieve suffering, is revealed by the doctrine of double effect to be an importantly different act than the giving of pain relief which may indeed cause the patient’s death. What distinguishes them is the presence or absence of an intent to end the patient’s life.

At this point, some proponents of euthanasia throw up their arms in exasperation. This type of double-effect analysis seems far too complicated, more like academic hairsplitting than an accurate description of how people do and should make practical decisions. It is indeed true that the palliative care case is complicated, and a perfect example of a hard case that seems to strain the capacities of our practical reasoning. Yet it is suggested here that this is more a result of the particularities of the morphine case than it is the doctrine of double effect. We use double-effect reasoning, and manifest an awareness of the difference between intention and foreseen consequences, all the time.

Consider the heart surgeon who performs risky surgeries. The goal is to heal her patients, which is clearly a good goal. Yet due to the nature of the risky surgery, she knows that (even with no blameworthy negligence) her surgeries will in fact cause the deaths of some (hopefully small) percentage of her patients. She intentionally performs hundreds of surgeries, even while knowing full well ahead of time that she will sadly cause the deaths of some of her patients, patients whose lives would have been longer had they not ended on her surgical table. She has clearly caused the death of some of her patients, and thus we can say that she “killed” people. But is this the same as intentionally ending lives? Of course not. We do indeed grasp the difference between intended acts and voluntary acts with foreseen consequences, even before someone teaches us the doctrine of double effect. Therefore, though analysis of intentionality and the use of the doctrine of double effect may indeed get complicated with hard cases, the source of that complication is life itself, and not the way we go about practical reasoning. It would be a mistake to let a hard case like palliative care prompt us to reject important tools for practical reasoning, such as the careful delineation of intent (rather than reliance solely upon foreseen consequences) and the doctrine of double effect.

What’s Wrong with Intending to End a Life You’ve Already Given Up On?

Of course, demonstrating that intentionally ending the life of a patient who is suffering and near death is different from actions that may cause death does not therefore mean that acts of euthanasia are wrong. It is the purpose of this part to demonstrate why the intentional ending of a patient’s life—which is euthanasia—is not only different from other acceptable acts, but also wrong. After all, there are some who recognize the difference intention makes and still claim that in certain rare cases it may be most loving to purposely end the life of a suffering patient.See Margaret Farley, “Issues in Contemporary Christian Ethics: The Choice of Death in a Medical Context,” Santa Clara Lectures, 1 no. 3 (1995): 1–19. It is important to see the allure of this position. Again, assume we are talking about one of those cases where it is indeed prudent to stop prolonging life. For many, the cessation of treatment will result in a relatively quick death. But what if it does not? What if the suffering goes on, and though death will certainly come, awaiting it is unbearable to the patient? Why not go the extra step and intentionally end this patient’s life?

Note how rare this case is. First, clearly the person must be conscious to have unbearable suffering, so we are not talking about any patients that are comatose or in persistent vegetative states. Second, given the advanced state of palliative care today, thankfully it is also the case that few conditions elude quality pain treatment. Of course, access to quality medical care is definitely lacking not only in the developing world, but even in our own nation, due to injustices in delivery of medical care. Surely everyone who participates in this conversation can be united in pursuing the greater availability of quality palliative care to all who need it.

So though these cases are rare, they do exist. Should we carefully delineate them morally—even legally—and permit the intentional ending of a patient’s life only under these rare conditions? This is what the citizens of Oregon have in fact done. But the answer offered here is no, for two reasons. The first is a prudential judgment, meaning it refers not to an absolute norm but rather to a judgment about what is best overall, in this case for the common good of society. Consider the effect of legalizing euthanasia in such rare cases. Would it really remain limited to those rare cases, or would such legalization lead to further practice of and legalization of euthanasia? This type of argument is called a slippery-slope argument. It basically says that permitting certain acts may have the unforeseen, or at least undesirable, consequence of leading to acts one did not really intend to permit. For instance, what would happen to vulnerable populations in our society, such as the poor, the uninsured, the lonely elderly, racial minorities—all groups proven to receive less adequate health care than other populations in our society? It is reasonable to suppose that the same pressures alive and well today to limit costly medical care to such populations would lead to explicit, or at least implicit, pressures on such persons to avail themselves of what society has deemed to be an acceptable act at the end of life: euthanasia. This must at least give us pause, especially if we are concerned about the vulnerable among us. And given the rarity of cases that would justify euthanasia to its proponents—and the fact that the very existence of those cases generally betrays the very same injustices in health care that euthanasia opponents fear—the pervasiveness of injustice in health-care delivery to vulnerable populations makes legalization of euthanasia imprudent.

Of course, some slippery-slope arguments sound alarmist fears among people to convince them not to pursue a course of action. These types of slippery-slope claims are the worst of moral arguments.See James F. Keenan, SJ, “What’s Your Worst Moral Argument?” America 164 (1993): 17–18, 28–30. The way to determine whether a slippery -slope claim is a legitimate argument or a case of alarmist fear-mongering is to see how logically connected the immediate course of action is to what is feared down the road. It is true that legislative curbs could be erected to try and ensure that pressure favoring euthanasia not be exerted on vulnerable populations such as the poor and elderly. It is also true that data is mixed from places where euthanasia in some form is legal. In the Netherlands, laws have indeed gotten progressively permissive (such that involuntary euthanasia for the nonconscious without advanced directives is now permissible), and numbers are on the rise. In Oregon, where only physician-assisted suicide is legal, there has been no broadening of the laws, and numbers have remained relatively small. So the data is mixed. But given the stakes, and the small number of cases this legitimately concerns, can it really be deemed prudent to legalize euthanasia in our nation today? The answer given here is no.

The second reason why intentionally ending suffering patients’ lives is not only different but wrong concerns an absolute norm rather than a prudential judgment. As noted in chapter 8, part of the moral bedrock of the Christian tradition is “that direct and voluntary [i.e., intentional] killing of an innocent human being is always gravely immoral.”Evangelium Vitae (Encyclical Letter, 1995), 57. This is true even where it seems that good may come of the evil act (see Rom. 3:8). Note two key terms in this absolute moral norm. The first is “intentional,” which already has been fully explained. The second is “innocent,” a word that explains why this norm does not necessarily apply in cases of warfare. Not all killing is the same, and thus recognitions of the permissibility of self defense or warfare do not at all directly translate into the permissibility of euthanasia.

Of course, what the issue of euthanasia offers most distinctly is a case where it seems that intentionally ending the patient’s life is in the patient’s best interest, since it ends her suffering. Indeed, the patient is presumably asking for it, and others have recognized that it is prudent to stop fighting to prolong life. Surely the prohibition against killing the innocent is meant to protect people. But it seems here that euthanasia in certain rare cases is actually a way to serve the patient’s best interests!

We are now at the very crux of the issue. Why is an intent to end a suffering patient’s life always and everywhere wrong? It is not enough to say it is playing God, or (more secularly), that it violates human rights, since those answers beg the question. That is, they assume the correct answer in providing their response. We are precisely trying to determine if it is ever a way to honor human dignity, or play with God, to euthanize a patient, much as we trust we are honoring dignity and cooperating with God when we send patients to a surgery even if it turns out to be deadly, or when we give pain killers that actually end up hastening death. Granted, these are non-intentional acts; but why is intentionally ending life always wrong?

One could claim the prohibition of intentional ending of life is an effective stopgap. It helps ensure that the slippery-slope concerns described above do not happen. Or, from a religious perspective, such a prohibition could be seen as a way to leave a gap for God to act, if the decisions we make are somehow wrong; in other words, if we can decide not to prolong life but not to end it, then God can intervene and keep the patient alive, if that is God’s desire. But this is inadequate. From a secular perspective, it is wrong to instrumentalize those who make up the rare cases, where intending death is appropriate (if that is true), only to guard against possible future harm to people in vulnerable positions. From a religious perspective, presumably God does not need our protection in the form of a purposeful gap to be able to act! Better to do our best to cooperate with God’s intentions than see God’s agency and our own in tension, and set things up to allow for God to win out in case we are wrong (as if God needs our help!).

This last comment on cooperating with God’s intentions addresses our question most directly. Christians believe that God is a God of life, and that death, sin, and suffering are not intended by God; rather, they are deviations from God’s plan. It is true, as stated in chapter 13, that God in God’s mercy brings enormous good out of even great evils such as death, by bringing people who have died into union with him. But though God allows death to happen, God does not intend death, nor should we.

This answer is one of many answers to our question that are part of the Christian tradition. For instance, euthanasia is interpreted by Christians to defy the divine command, “thou shall not kill.” Further, Christians believe that their lives are not their own, but rather gifts from God; and acts directly intended to terminate that gift are sinful. But, the fact, that Christians have additional resources to support the absolute norm against killing the innocent should not mislead one into thinking that this norm is only intelligible, or applicable, to Christians. To the contrary, this is a natural-law norm accessible and applicable to all.

How is it intelligible to those who are not Christian? That it is can be seen in the fact that it is current U.S. law (with the Oregon exception). How it is can be seen by recalling our work on intention in chapter 2. Recall that intentions are not merely transitive (impacting the world around us), but also intransitive (shaping our very selves). Though different acts may lead to the same (transitive) results, it is the intentionality that makes an act intransitive and shapes who we are. Intending to end the life of a patient, even out of mercy, shapes us into people who reject and attack life, rather than people who unequivocally support life, as when we patiently care for the dying. The willingness to intend to end an innocent life, even for the patient’s “own good,” is not only ripe for abuse, but changes the person so willing to act. Even in the presence of a well-meaning goal of ending suffering, performing acts whose immediate goal is to end life habituates a person into someone who acts against life. As a point of contrast, the person who intentionally administers painkillers, knowing that they may cause death, is still habituating himself into someone who cares for the dying, since that is the intention of the immediate act. This is why intention is what defines euthanasia, and why it is so crucial not to intend to end a patient’s life.

The preceding paragraph may make it seem as if the prohibition against intending to end a suffering patient’s life is more for the sake of the caregiver than the patient. After all, it is the patient who is suffering, so shouldn’t care for that patient take precedence over concern for how the caregiver habituates herself? In fact, this may even appear to be an occasion where the caregiver ought to be willing to give of herself, even at the risk of harm to her character. But this is wrong for two reasons. First, given the discussion of justice in chapter 7, recognition of the common good means that the patient’s own good is tied up in the flourishing of those around him, such that it is not actually in the best interest of the patient to be part of a community where intentionally ending life is part of people’s character. Second, and related to the first, even in the immediate moment, a caregiver’s intention to end life, even if well-meaning, pollutes the caregiving relationship. Rather than being supported by people who care for and suffer with him, the patient is cared for (or is he?) by people who are open to purposely ending his life. One could retort that such an act (euthanasia) would only be done with the patient’s consent (indeed, request). Even so, the active consideration of this option in such a situation, particularly at a time of great vulnerability for the patient, diminishes the caregiving encounter in a manner akin to the way intentionally ending a life warps the character in the caregiver. It makes the acceptance of life conditional, and turns a relationship defined by care into a relationship open to elimination of the patient. This is why many authors who write on this issue worry about the involvement of the medical (caregiving) community in the execution of euthanasia.This is a common topic in the literature on euthanasia. For a brief summary of the issue, see Richard Gula, “Moral Principles Shaping Public Policy on Euthanasia,” Second Opinion, 14 no. 1 (1990): 73–83. There is a fundamental disconnect between intentional care and intentional elimination.

Withholding or Withdrawing Life-Sustaining Treatment

The preceding parts of the sections have attempted to delineate the difference between intending the death of a patient and offering treatments that may actually cause a patient’s death, with a further claim that while the latter may be virtuous, the former never is. But there is another category of actions to consider. Treatments like the administration of painkillers (and even more obvious ones like heart surgery) are clearly intended for the good of the patient, and therefore fall under the doctrine of double effect, even when they in fact lead to a patient’s death. The patient’s death is a foreseen consequence, though not the intent of these acts, which is why they are distinguished from acts of euthanasia.

One of the reasons that virtuous caregivers are willing to treat patients in ways that may actually hasten their death is that human life, while an extraordinarily important good, is not absolute. If life were regarded as an absolute good, then nothing which could threaten it could be undertaken virtuously. This would apply not only to medical procedures such as surgeries and palliative care, but other human activities such as waging war, fighting fires, or even driving cars. Each of the latter is always undertaken by people with the foreseen (but unintended) consequence that it may lead to their death. If preserving and prolonging human life were an absolute value, none of these activities could be virtuous. This position has been called vitalism; life should be preserved and prolonged at all possible costs.See ibid. Thankfully, principled vitalists are few and far between. Few if any would rule out the willingness to sacrifice one’s own life for another in a situation such as a with a rescuing mother. And in the medical arena, given the advanced state of technology today, vitalism would mean trying to resuscitate every single person who dies, and using every treatment and piece of technology available at the end of life, no matter what the patient’s condition.

A main reason vitalism fails is that it assesses the good of life solely by the length of life. Length of life is not unimportant, for sure, and in general people naturally strive to prolong life. But if length of life alone is considered, prolonging life becomes an absolute norm. This fails to leave any room to make judgments about the quality of life. As chapter 13 on hope and the afterlife endeavors to show, the goal of the truly good life is fullness of life, which is not only measured by duration but by quality. (Virtues are the characteristics that give life such quality.) Firefighters and soldiers make judgments about the quality of life—both for themselves and their communities—and are willing to sacrifice length for quality. The same is true in the medical arena. We should not deny that quality-of-life judgments are indeed made during end-of-life decision making, the point made in section one of this chapter.

The question at issue here is the following: when a quality-of-life judgment is made, such that some particular medical treatment is refused or ceased, with the foreseen consequence that the patient may (indeed, in some cases virtually certainly will) die, what is the intent of such an act? Unlike cases where a treatment intended for the good of a patient unintentionally ends his life (such as heart surgery), here we have a death that results from a purposeful refusal or removal of treatment. Does such a refusal or removal constitute “an action or omission which of itself or by intention causes death?”Declaration on Euthanasia, ii. If so, it is euthanasia, and thus wrong, making it seem the vitalists are right. But if not, what then is the intent of such acts?

Consider two cases. First, a person in a persistent vegetative state (PVS) and unable to breathe is on a respirator to enable him to breathe. Though, of course, such things cannot be declared with total certainly, doctors are virtually certain after months of this condition that the patient will never recover, regain consciousness, or breathe on his own. If the family decides to take him off the respirator and he dies, what is their intent? Second, a ninety-year-old woman in the last stages of cancer is in and out of consciousness and in great suffering. At her prior request, and with the support of her family, she has a DNR (“do not resuscitate”) order on her medical chart, so that if she were to go into cardiac arrest she would not be revived by her doctors, even if such resuscitation may indeed prolong her life. Does her DNR order constitute an intent to end her life, and thus qualify as euthanasia?

It must be granted that in either case, the act performed (i.e., the object) can be driven by intent to end the patient’s life, and thus be an act of euthanasia. (The same, of course, can be said of palliative care.) If this were the case, it would be why the DNR order was given, or why the respirator was turned off, and this aim would be frustrated if the person somehow lived on (particularly in the latter case). But second, these objects may be driven by another intent, namely, the intent to stop prolonging the life of the patient with useless or burdensome treatments. The claim here, which is also the claim of the Catholic church and current U.S. law, is that a caregiver may withhold or withdraw life-prolonging treatment, resulting in the death of the patient, with the intent not to kill the patient but rather to avoid burdensome or useless treatments.

One of the main reasons debates about euthanasia can be so confusing is that people often label such acts euthanasia, most often passive euthanasia. But if the distinguishing feature of euthanasia is an intent to end a patient’s life, this is not necessarily the intent behind the act (though again, it may be, and if it is, the act is euthanasia). As in the case of the painkillers, here we have a voluntary act with the foreseen consequence of the patient’s death. How can we say death is not intended? This is especially true of this case vs. that of painkillers, since with the administration of painkillers there is at least an obvious alternate intention (relief of pain). What alternate intention exists here, and is this now mere hairsplitting, or worse, self-delusion?

The alternate intent may be to stop prolonging life with treatment that is useless or burdensome (terms examined below). This is obviously the case when some sort of treatment (like CPR) is withheld, as in the ninety-year-old cancer patient. But it is also the case in the removal of the respirator in the PVS patient. Though it may seem the patient is living without treatment, and is then interfered with (by the removal of the respirator, or “pulling the plug”), in reality the situation is better understood as one of ongoing treatment (i.e., the respirator) which is then stopped. The interference was happening all along, and then removed when deemed useless and burdensome. The intent of the act is the withholding or removal of futile treatment. Is this a self-deluding way to say we are not really killing the patient? Not at all. The evidence is the fact that on occasion people do continue to live when taken off a respirator. And certainly people continue to live before their DNR order is respected. When lives go on, the caregivers support and sustain the patient. They do not consider their aim (intent) frustrated if the person continues to live; their aim was to avoid needlessly prolonging life with treatment. If a person lives on without such treatment, their aim is still achieved! If it were not, presumably they would try to “finish the job” by performing some act (a different object) intended to end the patient’s life.

Note two observations about intention when withholding or withdrawing life-sustaining treatment. First, it is certainly true that people may actually harbor a malicious intent (to kill), and legally get away with it by performing an act that cannot be prosecuted, since it may be driven by a legal intent (not to prolong life). When this happens, the act is not virtuous, even if it is not prosecutable. Second, sometimes the intent to not prolong life is accompanied by a hope or desire that the loved one die sooner rather than later. We often hope and pray our suffering loved ones at the end of life may rest in a peaceful death to end their suffering, even while we refuse to end their lives ourselves. In fact, the patient himself may desire a speedy death to be delivered from suffering, and yet refuse to end his own life. The refusal to finish the job and end a life is not an act of cowardice, but the recognition that intending to end a life is a different act than hoping for deliverance from suffering (the point of the last part of this section). Thus family members may actually hope for a speedy death while withholding or withdrawing treatment. Sadly, this often engenders guilt in people in such situations when the patient dies. They may label this a case of having mixed intentions. But again, recall an intention guides actions.. In this case, the hope or wish for a speedy death is not an intention, since it does not drive the action. In such a case we do not, properly speaking, have mixed intentions; we have intentional action accompanied by wishes (that are not intentions). In such a case there should be no guilt, so long as the caregivers are acting to avoid useless or burdensome treatment rather than to end a life, two importantly different intentions even when the foreseen consequences are the same.

The repeated description of treatments as useless or burdensome requires some discussion. Though medical treatments generally prolong life, the point of medicine is not simply to prolong life but rather to enable people to live more fully (a goal that generally coincides with prolonging life). Sometimes medical treatment does not serve this purpose, even though it may prolong life. Two examples are the PVS patient and the ninety-year-old cancer patient already mentioned. In these cases, resuscitation or a respirator would indeed work, in that they prolong life. And in most cases those treatments should indeed be employed. Yet not always. When burdensome to patients and their loved ones, or useless by not serving a medical purpose, then these treatments can be refused.For further discussion of these terms, see Gilbert Meilander, Bioethics: a Primer for Christians (Grand Rapids: Eerdmans, 2005), 71. It is essential to note that these two terms refer to the treatment, not to the patient. It is not virtuous to cease treatment because one views a patient’s life as useless or burdensome. Even when we judge someone’s quality of life such that it is best to no longer fight on, labeling a person useless or burdensome is something else altogether—and incompatible both with respect for persons and with the virtue charity. But a medical treatment may indeed be labeled useless or burdensome.

Another way used to describe useless and burdensome treatments is by calling them extraordinary. Extraordinary treatments are those which are burdensome and/or useless, and thus can be refused without intending to end a patient’s life. The two cases above are good examples. Another would be the cancer patient whose standard treatment has proven ineffective, but is offered an experimental treatment which would entail moving across the country away from family, significant expense, and far from certain results. Such a treatment would be called extraordinary and could be refused without intending the patient’s death. In other words, saying no to such a treatment does not necessarily constitute an intent to die. Note that extraordinary treatments may indeed be virtuously undertaken; they just need not be. Different persons can come to different decisions on such matters and each be virtuous. To add further confusion, the same treatment may be extraordinary in some cases, but not in others. The respirator may be extraordinary for the PVS patient, but not burdensome or useless for a person who is in major surgery and expected to recover. A respirator is used in these latter cases all the time, and if someone were to remove it we could only describe such an act as intended to end the patient’s life.

This leads us to the companion term of extraordinary treatment, namely, ordinary treatment. An ordinary treatment is one that is not burdensome or useless. Therefore, its refusal or removal can only be driven by an intent to end a patient’s life. Sometimes a particular sort of act (object) can be driven by alternative intentions. For instance, one can remove someone from a respirator in order to end his life, or in order to cease burdensome or useless treatment. The act looks the same from the outside, but is importantly different due to intent. Some acts (objects), however, are so clear in their meaning that they can only be driven by one intention. This is what the Declaration on Euthanasia refers to when defining euthanasia as “an action or omission which by itself or by intention causes death.”Declaration on Euthanasia, ii. Even if a person tells herself she is doing it for another reason, we say this is self-delusion. For instance, if the ninety-year-old cancer patient acquires an infection that is easily treatable with an antibiotic, that treatment is ordinary. It is not burdensome or useless. If it is refused, there is no explanation for the act other than intending to end the patient’s life.

Of course, the rub is often deciding whether a treatment is rightly labeled ordinary or extraordinary. Though there is a rationale behind these labels, there is no precise formula available to determine the status of any and all treatments. Some cases are not contested, such as the ones offered so far in this part. Yet others are much more difficult, especially given the fact that usefulness and burden are terms that may be dependent on a patient’s particular status, and at different times or with different patients the same treatment may be ordinary or extraordinary. A currently contested example is the administration of AHN, or artificial hydration and nutrition. What could be more ordinary than giving a patient food and drink? This is indeed an ordinary treatment in the vast majority of cases. But there are cases of PVS patients who cannot be spoon-fed and who develop horrible infections from tube feeding. In such cases AHN is indeed providing a burden, and nearly all agree in such extreme cases that it can be removed. But what of conscious patients at the very end of life who can receive AHN, even though doing so will prolong their suffering? These are the cases that are debated today.

Debates such as these are dependent not only on clear thinking and precise principles from moral theology (intent, double effect, ordinary/ extraordinary, etc.), but also upon the medical facts of the case which are required in order to make judgments about burden, usefulness, and so on. This should not surprise us; after all we are dealing with an innerworldly activity accessible to unaided human reasoning and thus able to be governed by natural-law reasoning. That analysis cannot be done here. The point of this chapter has been to equip the reader with essential concepts for adjudicating which end-of-life decisions are virtuous, and which are not. With the conclusion of this discussion of ordinary and extraordinary treatments, that task is now complete.

The painstaking analysis of human action in the preceding parts may lead us to wonder why this chapter is found in the second half of this book. Recall the main claim of the second half of this book is that big-picture beliefs (like the belief commitments of the Christian faith) shape how we engage in innerworldly activities, and thus impact what acts are virtuous or not. That claim is again affirmed here. In terms of this chapter, it is most obviously seen in the first section’s discussion of when it is ever virtuous to welcome death. But it is also seen in the goal of medical treatment assumed throughout this chapter: to support and restore life most fully.

Of course, it is also evident in this chapter that Christian beliefs do not uniquely support that goal of medicine. Furthermore, no matter what one’s belief commitments, careful action analysis (as seen in the third section) is necessary which is attentive to intentionality, consequences, and so on. Hence, the issue of euthanasia is a particularly appropriate way to end the main body of this textbook. We see here the necessity of prudence, the interconnectedness of prudence and the other cardinal virtues (particularly justice), the importance of object/intention/circumstances, the usefulness of the doctrine of double effect, the place of absolute norms, and the importance of the formation of conscience and the habituation of our desires (particularly our fears concerning death and the end of life). All of these topics—addressed in the first half of this book—are seen here with euthanasia. They all constitute natural-law reasoning, since they concern activities accessible to unaided human reasoning.

All of these topics are also shaped by one’s big-picture belief commitments, including those of the Christian story articulated in this second half. So from a Christian perspective, starting from the three theological virtues enables us to see how faith in a God of life leads us to “play with God” by not ever intending the death of innocent persons. Our hope in life eternal allows us not to absolutize earthly life, and yet to see our actions here as continuous with our eternal destiny, such that life here can never be discarded casually or purposely acted against. Our love leads us to care patiently for those who suffer at the end of life, to be with them in their brokenness with trust that loving service to others in times of suffering is indeed the path to new life illuminated by Christ. We trust in God’s grace to support us not only in faith, hope and love, but also in the prudence, justice, fortitude, and temperance needed to live virtuously at the end of life. The argument against euthanasia in this chapter is not dependent on resources particular to Christianity. Yet that argument is indeed further illuminated and buttressed by the Christian tradition.

1. Why does this chapter dismiss the helpfulness of the slogan, “don’t play God!”?

2. Is suffering simply good? Can there be meaning in suffering? Be sure to explain the difference between educative and redemptive suffering.

3. True or False: “Suffering should be avoided at all costs.” Explain your answer.

4. Is dependency ever good? At what point does dependency inhibit a good life?

5. What is it that defines an act of euthanasia according to this chapter? Explain why or why not this way of determining whether an act counts as euthanasia is more helpful than distinctions such as “active/passive” or “natural/unnatural.”

6. Give the conditions of the doctrine of double effect. Using it, explain whether or not the administration of painkillers knowing it may hasten death can be a virtuous act.

7. What reasons are given here for why it is wrong to go the extra step and intentionally end a patient’s life to relieve suffering?

8. According to this chapter, what constitutes a virtuous intent while withholding or removing treatment? When is such an act virtuous?

9. Explain the difference between ordinary and extraordinary forms of treatment, giving examples of each. Why is it always immoral to withhold or withdraw ordinary treatments?

educative vs. redemptive suffering, mutual dependency, active/passive, natural vs. unnatural, euthanasia, physician-assisted suicide, palliative care, doctrine of double effect, slippery-slope argument, vitalism, ordinary vs. extraordinary treatment, artificial hydration and nutrition

1. If people say in debates over euthanasia, “don’t play God!” what do they really mean? What could they say instead, or why is this sufficient?

2. In what ways can we live now, before facing end-of-life decisions, to develop good habits so as to be able to find meaning in suffering, or live out an appropriate sense of mutual dependence?

3. How would you respond to someone who said to you, “I agree with passive euthanasia, but not active euthanasia”?

4. Try to think of examples from everyday life where we can clearly see the difference between voluntarily acting in a way that brings about foreseen consequences, and intending those consequences. Do you agree with the difference between these two?

5. What is your own position on whether or not it can ever be permissible to intentionally end a patient’s life in order to relieve suffering?

6. Is artificial hydration and nutrition an ordinary or extraordinary medical treatment? Or can it be either? Explain.

The literature on euthanasia, let alone broader issues in bioethics, is simply enormous. The Vatican’s Declaration on Euthanasia is a succinct statement on the issue from a moral-theological perspective. See also John Paul II’s encyclical Evangelium Vitae, which offers a powerful exposition of the centrality of affirming life and refusing to intend the death of innocents. The sections focused on euthanasia are 64–67. John Keown’s (ed.) Euthanasia Examined: Ethical, Clinical and Legal Perspectives is a helpful overview of various dimensions of the issue, including representatives from differing viewpoints. For a helpful examination, from a Catholic perspective, of recent debates over artificial hydration and nutrition, see Christopher Tollefson (ed.), Artificial Hydration and Nutrition: The New Catholic Debate and Ronald P. Hamel and James Walters (ed.) Artificial Hydration and Nutrition in the Permanently Unconscious Patient: the Catholic Debate.