Assisted Dying – Theological Perspectives
The Rev’d Professor Kenneth Boyd
Kenneth Boyd is Professor Emeritus and Senior Honorary Professorial Fellow in the Edinburgh University College of Medicine and Veterinary Medicine where he teaches medical and biomedical ethics. An honorary Vice-President of the Institute of Medical Ethics and Associate Editor of the Journal of Medical Ethics, he has published on various aspects of medical, science, and animal ethics as well as on Scottish church history and on S.T. Coleridge. He is an ordained minister of the Church of Scotland and a nonstipendiary team priest of the Scottish Episcopal Church of St John the Evangelist, Princes Street, Edinburgh.
In the absence of unequivocal scriptural guidance, and with traditional arguments against suicide challenged both philosophically and in the context of modern medicine and society, theological perspectives on assisted dying are most appropriately expressed not ‘in the language of decision-making and law’, but in that of ‘spiritual journey and psychological meaning’. Avoiding fantasy by attention to reality while attending on God, is a way of enabling more autonomous end-of-life attitudes and decisions, and of sustaining hope beyond the loss of autonomy of will and action.
ASSISTED DYING: THEOLOGICAL PERSPECTIVES
“No one in the Bible died like this,” an elderly hospital patient recently informed her doctor. ‘Not long ago’, the doctor thinks, ‘people generally “got sick and died” – all in one sentence and all in a few days or weeks.’ But now, most people ‘grow old and accumulate diseases for a long time before dying…the great success of modern medicine has been to transform acute causes of death into chronic illnesses… Many elderly people are inching toward oblivion with small losses every few weeks or months’.
Now this, I suggest, is the new demographic and epidemiological context that theological perspectives on assisted dying now need to address. But that is not easy. It is not just that the Bible has little to say about how so many people die today, or more generally about many of the moral dilemmas of modern medical progress. It is also that the Bible, in common with other foundational religious texts, offers no unambiguous guidance on the ethics of suicide. It was only later, in the Jewish, Christian and Islamic traditions, that theological perspectives on the question developed, and suicide was condemned, for a variety of reasons and with a few, contested, exceptions. These perspectives were required partly to distinguish suicide from martyrdom; and they were arrived at by interpreting the limited references to suicide in sacred texts, in the light not only of each tradition’s wider theological views, but also of the social and cultural assumptions of the time.
Other religious and philosophical traditions, of course, have been more ambivalent about suicide, or have even approved of it in certain circumstances. These traditions however, with the exception of some aspects of Stoicism, have had less direct influence on contemporary Western arguments for and against assisted dying, than have had the three Abrahamic religions, and in particular the Christian synthesis of Hebrew and Greek thought. For the present purpose then, I shall concentrate, if I may, on how Christian theological perspectives on suicide developed, how they were then challenged, and how they might address the contemporary context.
Before doing this however, let me make one more preliminary remark. The extent to which different Christian Churches authoritatively and unequivocally articulate their theological perspective on suicide and euthanasia varies; and even where it is articulated authoritatively and unequivocally, the extent to which individual members of the denomination agree with it also varies. One reason for this variety, I suggest, is that theology talks in the third person about what individual believers encounter in the first and second. As the 20th century Japanese philosopher Nishida observed: ‘Religion is about God’, but ‘what can be conceived or not conceived is not God’; and if we insist on talking about religion as about what can or cannot be conceived in a ‘belief system’, we ‘end up talking about something else’.
Turning back to the theological tradition however, it is generally agreed that Christian objections to suicide were consolidated in the early 5th century by St Augustine. Augustine argued that suicide disobeyed the scriptural commandment not to kill, was cowardly, and deprived the sinner of a chance to repent. Only a specific divine command – as in the case of Samson pulling the temple of the Philistines down on his own as well as their heads – could justify suicide; and Augustine did not support the exception made by some of his predecessors, that Christian women in times of persecution were justified in killing themselves to avoid being raped.
Augustine’s theological perspective on suicide was generally accepted in the Western Church for the rest of the first millennium and after. Eight centuries after Augustine however, St Thomas Aquinas refined the Church’s position with some more philosophical arguments. Aquinas taught that it was unlawful to kill oneself for three reasons: first, suicide was contrary to natural law and charity to oneself; second, it injured the community to which the suicide belonged; and third, because life was a gift from God, it deprived God of his property and power to decide about life and death.
In their time, these were powerful arguments against suicide. Natural law, based on philosophical rather than scientific theories of what was essential to human nature, held that everything loved and sought to perpetuate itself. Aquinas’ argument about suicide harming the community was (and for many still is) readily understandable. “Shouldn’t he have thought of the effect on his family?” And in the hierarchical mind-set of the middle ages, the argument about usurping the function of our ultimate superior was highly persuasive.
Aquinas’ views however eventually were challenged, in the seventeenth century most notably by John Donne in his Biathanatos, which for prudential reasons he did not publish in his lifetime. Going back beyond the received wisdom of Augustine to the other fathers of the Church and especially to scripture, Donne discovered much more heterogeneous and equivocal views on the subject. Philosophically moreover, he found Aquinas lacking. Aquinas’ first argument, that it was natural to keep ourselves alive, Donne said, was too sweeping: there was also a ‘natural desire of dying’, often expressed in scripture and by saints and martyrs. The second and third arguments also were too sweeping: the preacher who was to claim ‘Any man’s death diminishes me’ could not deny that some suicides harmed their community, and that God’s gifts could be misused. But, whether or not there was harm or misuse in a particular case was a matter for conscience to determine in the light of intentions, motives and circumstances. It was for conscience to decide whether suicide was committed for self-interested motives or, as in Christ’s own case, who died by ‘His own act, and before his natural time’ [III.iv.5], as an act of self-sacrifice.
A more pugilistic challenge to the idea that suicide was morally impermissible came a century later in David Hume’s essay on the subject. Whether a suicide harms the community, Hume argues in a utilitarian vein, depends on what the person still has to offer the community: after retirement, this may be very little, and may eventually be outweighed by his continued life becoming a burden not only to the community but also to himself. As for Aquinas’ theological arguments based on natural law, Hume interprets these as if they referred to causal laws of nature, which humans break all the time by protecting themselves from harmful natural events: if we are allowed to turn our head aside to avoid a falling stone, or to divert a river to avoid a flood, “Where is then the crime of turning a few ounces of blood from their natural channel?” Or again, on the other hand, if Providence really is sovereign, nothing can happen without its consent, and so “neither does my death, however voluntary, happen without its consent”. Hume even goes so far as to claim that if a man takes his own life because of his misery, but at the same time sincerely thanks God “both for the good which I have enjoyed, and for the power which I am endowed of escaping the ills that threaten me”, how can this be evil?
While the arguments of Donne and Hume were challenged on various grounds by subsequent theologians and philosophers, they eventually helped to make the unequivocal Augustinian and Thomistic condemnation of suicide seem increasingly untenable, and this in time contributed to the decriminalisation and eventual medicalisation of suicide. Today, even the Thomist tradition’s staunchest defender, the Roman Catholic Church, while ‘it condemns the act of euthanasia as a “violation of the divine law, an offense against the dignity of the human person, a crime against life, and an attack on humanity”’, speaks of the agent in a vein reminiscient of medicalisation, when it states that in ‘cases of “prolonged and barely tolerable pain… the guilt of the [suffering] individual may be reduced or completely absent’.
Not even Hume, however, argued that every suicide could be morally justified. The view that anyone has the moral right to end their own life at any time and for whatever reason is difficult to defend, for reasons which are similar to Aquinas’ argument about harm to the community. The moral community needs, at the very least, to be satisfied that the agent is autonomous, in the principled Kantian sense of acting only after having duly considered the reasonableness of his intentions and motives in the light of the circumstances and the likely consequences. The moral community, clearly, cannot always prevent the Werthers of this world, or those overcome by social shame others consider trivial, from ending their own lives prematurely. But it normally feels entitled to withhold moral approval, if only to discourage imitation by others.
But what of circumstances such as those envisaged by Hume, where an autonomous individual has duly considered the reasonableness of his intentions and motives in the light of the circumstances and likely consequences, and concludes that he has little or nothing left to give to the community, and what little he has is outweighed by his continued life becoming a burden not only to the community but also to himself? This, perhaps, is how some of those I mentioned at the outset, ‘inching toward oblivion with small losses every few weeks or months’ may see themselves, and decide, autonomously, that in their case, suicide or euthanasia is morally justified. Would seeing their situation in a theological perspective make any difference to this decision?
To try to answer that question, let me quote another remark by the doctor I mentioned. Our current ‘conceptual apparatus’ for thinking about the ethics of end of life care, she argues, betrays a ‘lack of social understanding’ that is illustrated by our using ‘the language of decision-making and law more often than that of spiritual journey and psychological meaning’.
Now in ‘the language of decision-making and law’, a theological perspective probably can make little difference if and when, in a pluralistic society, a person decides, autonomously, that in their case, suicide or euthanasia is morally justified. We do not live in a theocracy – a society ruled not by God, but by some powerful people’s ideas about God – but in an elective democracy where the views which persuade the largest public prevail; and that public may well be duly persuaded that the potential risks of legalising euthanasia – as previously of decriminalising suicide – are outweighed by the justice of respecting individual autonomy. It is rather in what happens next, whether or not society decides to legalise euthanasia, that a theological perspective may make a difference, and do so in terms of what the doctor calls the language ‘of spiritual journey and psychological meaning’.
The difference that a theological perspective may make, in other words, is not so much in how the autonomous individual sees their decision, as in how they see the world and themselves. Iris Murdoch once observed, that how we see, or ‘attend to’ reality and ourselves ‘in between… explicit moral choices… is crucial’: ‘if’, she writes, ‘we consider what the work of attention is like, how continuously it goes on, and how imperceptibly it builds up structures of value round about us, we shall not be surprised that at crucial moments of choice most of the business of choosing is already over.’ Attention to reality and to ourselves, Murdoch argues, is necessary especially to liberate us from ‘fantasy… the tissue of self-aggrandizing and consoling wishes and dreams which prevents one from seeing what is there outside one’. But fantasy, ‘the fat relentless ego’ she warns, ‘is itself a powerful system of energy’ which we need to counteract by ‘attention to reality’. In this respect, she suggests, the ‘religious believer, especially if his God is conceived of as a person, is in the fortunate position of being able to focus his thought upon something which is a source of energy’. ‘That God, attended to, is a powerful source of (often good) energy’ she writes, ‘is a psychological fact.’
Now attending to God, as Murdoch goes on to argue, is not the only way of being delivered from fantasy, and clearly fantasy can entrap people into making God in their own or another dubious image. Murdoch’s definition of God is ‘a single perfect transcendent non-representable and necessarily real object of attention’, and ‘nonrepresentable’ is as crucial for theology as ‘real’. Again, as Nishida argues: ‘what can be conceived or not conceived is not God’. With that proviso however, the following I think may reasonably be argued. If attending on God enables one to avoid fantasies about God as well as about oneself, a theological perspective on suicide and, importantly, on what leads up to considering suicide, may help individuals make decisions that are more, and not less, autonomous. In a theological perspective, that is, the successes and failures of life that fantasy magnifies, may be seen in a more sober, but also a more self-forgiving light, relativising the excesses of pride and despair, and investing autonomy with the courage to trust that no frailty, fault or failure is ultimately irredeemable. In a theological perspective too, the belief that human dignity is inalienable and not diminished or destroyed by dependency on others, may augment the autonomy of those who find little encouragement in Humean utilitarian calculations about their contribution to society. And finally, the theological sense that, even when it is no longer possible to exercise autonomy of will and action, there is hope beyond autonomy, may encourage a more objective assessment of one’s present and future circumstances.
Not all theological perspectives however are benign. Telling others that suffering can be good for them betrays the truth of what it argues, and while religion can be life enhancing, it can also be the opposite. Having a theological perspective on life and death moreover does not mean that at the end of a long life, as of a long day, it is wrong to decide that one has had enough – at least for now. And with reference to that ‘for now’, it would be wrong of me to omit, just because it is culturally unfashionable, that a theological perspective also speaks of the incalculable dimension of eternity.
Deciding to help oneself to a whisky to bring on sleep at the end of a long day however is a rather simpler matter than securing the means to ensure that one will not wake up in this world. Today’s ‘perfect philosophical situation’ where ‘the means to commit suicide will implicate no one other than the person who desires to end his/her life’ seems to me not just practically, but logically impossible. In theological perspective it also, I think, avoids the spiritual challenge of assisted dying for the doctors whom almost everyone who advocates assisted dying wishes to provide that assistance. For doctors, weighing up their duties to preserve life, to relieve suffering and to be honest with the patient, the time may come when they need to discern whether the patient’s case is sufficiently extreme to justify moving out of their own comfort zone, albeit of course in consultation with colleagues, the patient, and their family. How doctors negotiate that passage in good conscience, I suspect, is one of the most significant formative struggles in the making of a good doctor. But that perhaps is subject for another day.
1 Lynn J. Living Long in Fragile Health Hastings Center Report 35, 6 supplement Nov-Dec 2005, p. s14 (article)
2 Nishida K. Last Writings: Nothingness and the Religious Worldview Univ Hawaii Press 1987:48
3 Campbell C.S. Religious Ethics and Active Euthanasia in a Pluralistic Society Kennedy Institute of Ethics Journal 2,3: 253-277
4 Murdoch I. The Sovereignty of Good Routledge 1970, ch 2
This paper was posted on www.anglicanism.org August 2013