By Rev. J. Daniel Mindling, O.F.M. Cap.
He taught us that to understand death with dignity, first accept the dignity of life. Human dignity is an undeserved gift, not an earned status. The dignity of life springs from its source. We come to be by the loving action of God the Creator. "What is man that you are mindful of him, and the son of man that you care for him? You have made him little less than a god, and crown him with glory and honor" (Psalm 8:5). The dignity of life is beyond price. We have been ransomed not with perishable things such as silver or gold, but with the precious blood of Christ (1 Peter 1:18- 19). The dignity of life is clear from our calling. God's plan for human beings is that they should "be conformed to the image of his Son" (Romans 8:29). "For God created man for incorruption, and made him in the image of his own eternity" (Wisdom 2:23).i
All who respect their God-given dignity are called to be heralds of a "culture of life." Christ's mission was to every human person, and our Lord had a passionate concern for the sick, the suffering, and the dying. In our own time, Christ continues his mission, and his preference for the vulnerable, through his Church. Christ looks mercifully upon us now and at the hour of our death, and the Church proclaims solidarity with our brothers and sisters at the end of their earthly journey. The Church is a patient advocate, working to ensure proper care for the sick and dying by promoting respect for their dignity. The Church is physician and nurse, the Good Samaritan who treats the wounded and abandoned and never walks by. The Church is also the innkeeper who provides the hospital, nursing home, and hospice for care and comfort.ii Pope John Paul, who was no stranger to sickness and suffering, raised the prophetic voice of the Church compassionately, often insisting on the care which is due to the sick and dying.
Traditionally, Catholics have prayed for the grace of a happy death: From a sudden and unprovided death, deliver us, O Lord. Now, advances in modern medicine increasingly pose the challenge of coping with a terminal illness which may last months or even years. Rather than worrying only about a sudden death, many today confront fears of a prolonged and debilitating illness, of being a burden on others, and of facing a path possibly marked by suffering.iii
"The church knows that the moment of death is always accompanied by particularly intense human sentiments: an earthy life is ending, the emotional, generational, and social ties that are part of the person's inner self are dissolving; people who are dying and those who assist them are aware of the conflict between hope in immortality and the unknown which troubles even the most enlightened minds. The church lifts her voice so that the dying are not offended but are given every loving care and are not left alone as they prepare to cross the threshold of time to enter eternity."iv
"The awareness that the dying person will soon meet God for all eternity should impel his or her relatives, loved ones, the medical, health-care and religious personnel, to help him or her in this decisive phase of life, with concern that pays attention to every aspect of existence, including the spiritual."v
And while true compassion "encourages every reasonable effort for the patient's recovery [, at] the same time, it helps draw the line when it is clear that no further treatment will serve this purpose. The refusal of aggressive treatment is neither a rejection of the patient nor of his or her life. Indeed, the object of the decision on whether to begin or to continue a treatment has nothing to do with the value of the patient's life, but rather with whether such medical intervention is beneficial for the patient. The possible decision either not to start or to halt a treatment will be deemed ethically correct if the treatment is ineffective or obviously disproportionate to the aims of sustaining life or recovering health. Consequently, the decision to forego aggressive treatment is an expression of the respect that is due to the patient at every moment."vi From the patient's perspective, this is not "giving up" nor disregarding the obligation to care for oneself, rather, it is an acceptance of the human condition in the face of life threatening illness.vii
Especially at the end of life, when it is clear that death is imminent and inevitable no matter what medical procedures are attempted, one may refuse treatment "that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted."viii Even at the stage of terminal illness when proportionate and effective treatment is no longer possible, however, palliative care is still appropriate and needed. The aim of such care can include alleviating many kinds of physical, psychological and mental suffering. Such care, said John Paul II, may involve a team of specialists with medical, psychological and religious qualifications who work together to support the patient in facing death.ix
Dying often includes pain and suffering.x Pope John Paul II admitted to his own personal sufferings, and proclaimed that these offered him a new source of strength for his ministry as Pope.xi We read in Evangelium Vitae (no. 67): "Living to the Lord ...means recognizing that suffering, while still an evil and a trial in itself, can always become a source of good. It becomes such if it is experienced for love and with love through sharing, by God's gracious gift and one's own personal and free choice, in the suffering of Christ Crucified. In this way, the person who lives his suffering in the Lord grows more fully conformed to him (cf. Phil 3:10; 1 Pet 2:21) and more closely associated with his redemptive work on behalf of the Church and humanity. This was the experience of Saint Paul, which every person who suffers is called to relive: 'I rejoice in my sufferings for your sake, and in my flesh I complete what is lacking in Christ's afflictions for the sake of his Body, that is, the Church' (Col 1:24)."
Ethical questions can arise regarding the use of pain medication. Pain should be managed in such a way as to allow patients to prepare for death while fully conscious. The dying should be kept as free of pain as possible. Some wish to blur the distinction between the use of medication to manage pain even at the risk of hastening the dying process, and the deliberate administration of a lethal overdose of pain medication. Those who claim the latter is mercy killing fail to recognize that true "compassion" leads to sharing another's pain; it does not kill the person whose suffering we cannot bear.xii
Sadly, there are physicians who see their role as assisting patients to end their own lives. What a tragedy it is that the very people trained to heal the injured and care for the sick, have become dealers in death. Pope John Paul II was blunt in his condemnation. Even if a patient requests assisted suicide, it remains an "inexcusable injustice." Although controversies over physician assisted suicide might seem to have come up only in our own time, he quotes St. Augustine who wrote over 1500 years ago: "it is never licit to kill another: even if he should wish it, indeed if he request it because, hanging between life and death, he begs for help in freeing the soul struggling against the bonds of the body and longing to be released; nor is it licit even when a sick person is no longer able to live."xiii
Especially in light of the tragic case of Terri Schiavo, Pope John Paul II left no doubt about the Church's clear teaching regarding those in a so-called "persistent vegetative state" (PVS). In the opinion of their doctors, these patients have suffered such severe neurological damage that they can no longer give any indication that they are aware of themselves or of their environment. It is unfortunate that their state is labeled "vegetative." Human persons are not vegetables. Such regrettable terminology may lead some to conclude falsely that these handicapped persons are more like vegetables than human beings. This is simply not true. All disabled persons have basic rights.xiv Although their higher cognitive functions may be seriously impaired, these patients are human beings with the same intrinsic value and personal dignity as any other human person.
Caution should be exercised even regarding the diagnosis of PVS. It is true that the longer such a state persists, the less likely the patient will recover. Nevertheless, at times this label is applied incorrectly, and there are more than a few cases reported in the literature of persons who have emerged from a "vegetative" state after appropriate treatment or who have recovered at least partially, even after many years. "We can thus state that medical science, up till now, is still unable to predict with certainty those, among patients in this condition, who will recover and who will not."xv
PVS patients, like all other patients, have a right to basic health care. They should be kept comfortable, clean, and warm. Care should be taken to prevent complications associated with being confined to bed. They should be given appropriate rehabilitative care and monitored for signs of improvement. Families who bear the heavy burden of dealing with this condition should be assisted by the rest of society, as true solidarity demands.
Pope John Paul II also resolved a long standing debate about life sustaining care for PVS patients. He taught unequivocally that there is a moral obligation on care providers. These patients should be provided food and water, even when these are supplied through a feeding tube. It is unjust to refuse to initiate or continue such basic care based on the quality of their life or on a claim that such care is too expensive. It is unjust to discontinue it even because of a decreased hope for recovery. John Paul II's statement is explicit. Nutrition and hydration is a natural means of preserving life, and "should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering."xvi
Patients often want to direct their care in the event that they become unable to communicate their wishes. The Holy Father's statement that PVS patients should be given nutrition and hydration, as part of the ordinary care to which all are entitled, raises questions about advance directives. Living wills should not include a statement that refuses nutrition and hydration in the event that one is diagnosed in a persistent vegetative state. It is, in principle, ordinary and proportionate care which is morally obligatory.
There is great confusion about death with dignity. What John Paul II rightly called the "culture of death" disregards the sanctity and dignity of life, and so misunderstands dying. It claims that life has value only to the extent that it is productive, when it brings pleasure and well being. In this vision, "death is considered "senseless" if it suddenly interrupts a life still open to a future of new and interesting experiences. But it becomes a "rightful liberation" once life is held to be no longer meaningful because it is filled with pain and inexorably doomed to even greater suffering."xvii
Because the culture of death disregards God, it also overestimates human autonomy with respect to life. Within the culture of death, "the fear of a prolonged or painful death and concerns about being a burden on loved ones tempts some to try to take control of death and bring it about before its time, "gently" ending one's own life or the life of others."xviii
By contrast, a culture of life will reject all forms of euthanasia. Euthanasia is "an action or omission which of itself and by intention causes death, with the purpose of eliminating all suffering."xix It is "a grave violation of the Law of God, since it is the deliberate and morally unacceptable killing of a human person."xx "Euthanasia is one of those tragedies caused by an ethic that claims to dictate who should live and who should die. Even if it is motivated by sentiments of a misconstrued compassion or of a misunderstood preservation of dignity, euthanasia actually eliminates the person instead of relieving the individual of suffering."xxi
"Even when not motivated by a selfish refusal to be burdened with the life of someone who is suffering, euthanasia must be called a false mercy, and indeed a disturbing "perversion" of mercy. True "compassion" leads to sharing another's pain; it does not kill the person whose suffering we cannot bear. Moreover, the act of euthanasia appears all the more perverse if it is carried out by those, like relatives, who are supposed to treat a family member with patience and love, or by those, such as doctors, who by virtue of their specific profession are supposed to care for the sick person even in the most painful terminal stages."xxii
"None of us lives to himself, and none of us dies to himself. If we live, we live to the Lord, and if we die, we die to the Lord; so then, whether we live or whether we die, we are the Lord's" (Rom 14:7-8). Dying to the Lord means experiencing one's death as the supreme act of obedience to the Father (cf. Phil 2:8), being ready to meet death at the "hour" willed and chosen by him (cf. Jn 13:1), which can only mean when one's earthly pilgrimage is completed."xxiii
Last but not least, respect for the dignity and sanctity of life of patients includes concern for their spiritual needs. "The terminally ill in particular deserve the solidarity, communion and affection of those around them; they often need to be able to forgive and to be forgiven, to make peace with God and with others." The sacrament of the sick, confession, and viaticum acknowledge and celebrate the very relationship with God through which we have received the dignity and sanctity of life, especially as a prelude to the final journey to our Father's house.xxiv
John Paul II never tired of praying for the help of the Mother of God, especially for the sick and dying. No summary of his catechesis is complete without turning our eyes to our Mother who stood vigil at the cross of her Son. "I entrust all of you to the Most Holy Virgin ... may she help every Christian to witness that the only authentic answer to pain, suffering and death is Christ our Lord, who died and rose for us."xxv
Fr. Mindling is Academic Dean, Mount St. Mary's Seminary in Emmitsburg, Maryland and a consultant to the U.S. Conference of Catholic Bishops' Committee for Pro-Life Activities.
i Evangelium Vitae (The Gospel of Life), 1995, no. 7.
ii Motu Proprio, "Dolentium Hominum" which established the Pontifical Commission for the Apostolate of Health Care Workers, February 11, 1985. Cf. Address on the 8th World Day of the Sick, August 6, 1999.
iii "Dying is also part of life." Pope John Paul II, Address at the Rennweg Hospice in Vienna, June 21, 1998.
iv "Love and Solidarity for the Dying." Pope John Paul II, Address to the Pontifical Academy for Life, February 27, 1999.
v "Faith responds to fears about death." Pope John Paul II, Address to an international congress on the care of the dying, March 17, 1992.
vi Address of John Paul II to the participants in the 19th International Conference of the Pontifical Council for Health Pastoral Care, November 12, 2004, no.4.
vii Evangelium Vitae (The Gospel of Life), no. 64.
viii Congregation for the Doctrine of the Faith (CDF). "Declaration on Euthanasia," 1980, part 4.
ix Ibid. Cf. Evangelium Vitae (The Gospel of Life), no. 65.
x Salvifici Dolores (On the Christian Meaning of Human Suffering), 1984. See especially the Address for the 10th World Day of the Sick, August, 6, 2001, para. 2.
xi Address for the 9th World Day of the Sick, August 22, 2000.
xii Evangelium Vitae (The Gospel of Life), no. 67. "Medicines capable of alleviating or suppressing pain may be given to a dying person, even if this therapy may indirectly shorten the person's life so long as the intent is not to hasten death." USCCB, Ethical and Religious Directives, no. 61.
xiii Evangelium Vitae (The Gospel of Life), no. 66.
xiv "The Inalienable Rights of the Disabled." Address of Pope John Paul II to the Pontifical Council for Pastoral Assistance to Health Care Workers, November 21, 1993.
xv Address of John Paul II to the Participants in the International Congress on Life-Sustaining Treatments and the Vegetative State: Scientific Advances and Ethical Dilemmas, March 20, 2004.
xvi Ibid.
xvii Evangelium Vitae (The Gospel of Life), no. 64.
xviii Ibid.
xix CDF. "Declaration on Euthanasia," 1980.
xx Evangelium Vitae (The Gospel of Life), no. 65.
xxi Address of John Paul II to the Participants in the International Congress on Life-Sustaining Treatments and the Vegetative State: Scientific Advances and Ethical Dilemmas, March 20, 2004.
xxii Evangelium Vitae (The Gospel of Life), no. 65.
xxiii Evangelium Vitae (The Gospel of Life), no. 67.
xxiv "Dying is also part of life." Address at the Rennweg Hospice in Vienna, June 21, 1998.
xxv "Message for the 12th World Day of the Sick," February 12, 2004. This series of messages began in 1992.