The Concept of Suicide

Suicide is the act of intentionally taking one’s life and is distinguished from natural death. There may be many reasons why it is done; such as to end one’s suffering, to avert financial ruins and to escape unbearable pain. Where there is no intention to end one’s life, there is no suicide. Thus those who risk their life in order to save others or those who refuse to renounce their faith knowing that this will mean their death do not commit suicide when they die as a result of this action because they do not explicitly intend their own deaths.[1]

Assisted suicide occurs when one person intentionally gives another the means or opportunity to take his or her own life at the latter’s request often to relieve the person’s pain and suffering. For example, if a wife were to give her husband, who was terminally ill with cancer of the colon and in severe pain, a large quantity of poison at his request, this would be assisted suicide.

Physician Assisted Suicide occurs when a physician helps a person take his or her own life by giving advice, writing a prescription for lethal medication, or assisting the individual with some device which allows the person to take his or her own life. The physician lends expertise, the person does the act.[2]

For instance if a physician were to give a patient with a terminal condition who requested it a prescription for a large dose of barbiturates, knowing that the patient use the medication to commit suicide, this would be physician-assisted suicide. The Christian Medical Fellowship in the United Kingdom and Christian Medical and Dental Society in the United States opposes physician-assisted suicide in any form. [3]

Euthanasia is a term that has not been used consistently. In original Greek, it means “good death.” In modern usage, it has taken a different, more specific meaning. Euthanasia has come ‘to mean that one person intentionally causes the death of another who is terminally or seriously ill, often to end the latter’s pain and suffering’[4]

Usually when euthanasia is mentioned, it is meant active euthanasia i.e. with intention to cause death, an action was taken. For example if a father were to inject his son, who is in great agony as he was dying, with a lethal dose of a drug in order to end his son’s suffering, this will be active euthanasia.Passive euthanasia is used to describe the action of withdrawing and withholding treatment with the results that death occurs as it would as a natural consequence of the disease process.

The Christian Medical Fellowship has always argued that the concepts of ‘active’ and ‘passive’ euthanasia are unnecessary and confusing when it is applied to physicians. They believe it is more helpful to use the concept of intention. What did the physician intend when he or she performed the act? What did the physician intend when he or she omitted to act? This discussion was submitted to the Select Committee of the House of Lords on Medical Ethics during its deliberation on euthanasia:

A deliberate intervention to end life is always morally wrong and should remain unlawful. An omission may be an example of euthanasia (and therefore morally wrong)

if its intention is solely to cause death. However, an omission would be a good example of good medical practice if its intention was, say, to maximise the quality of life remaining to the patient, or to respect the wishes of the patient and his family. The difference lies in the intention.[5]

Similarly the Christian Medical and Dental Society urged,“We do not oppose withdrawal or failure to institute artificial means of life support inpatients who are clearly rapidly and irreversibly deteriorating, in whom death is imminent beyond reasonable hope of recovery.”[6] The American Medical Association Judicial Council wrote:

“ …a patient’s coma is beyond doubt irreversible and there are adequate safeguards to confirm the accuracy of the diagnosis and with the concurrence of those who has responsibility for the care of the patient, it is not unethical to discontinue all means of

life prolonging treatment… includes medication and artificially or technologically supplied respiration, nutrition, or hydration”.[7]

However, things become complicated when we come to the cases of people in coma that is dependent on tube feeding for their fluid and nutritional needs. Is tube feeding a basic care or an artificial means of life support? Removal of tube feeding will result in the death of these patients, more from dehydration than starvation.

A secular consensus developed that artificially administered fluids and nutrition are different from eating and drinking, are modes of treatment, and are thus optional like any other treatment. This opinion is reflected in position statements from the AMA, the American Geriatrics Society and the American Academy of Neurology.

Many Christians have been reluctant to join this secular consensus. They refer to Jesus’ mention of his disciples giving a cup of cold water in his name (Matt 10:42, Mark 9:41) and the pleading of the rich man in hell for the beggar Lazarus to dip his finger in water to cool his tongue and ease his agony (Luke 16:24) These passages assume that such actions would both sustain life and/or relieve suffering.[8]

“…even if one does not place some positive act of violence but simply omits something necessary to preserve life, he can be guilty of euthanasia. It all depends on his intention. If his intention is to spare the patient a burdensome treatment, or one that is useless to preserve life, the omission can be justified. But if his intention is to bring on death, it is

euthanasia. Since the latter intention is present when nutrition and hydration are omitted for quality of life reasons, the failure to provide them has to be condemned as intentional euthanasia by omission”.[9]

Voluntary euthanasia occurs when another person, out of compassion, does an action with the intention of ending the life of a suffering patient at his or her request.[10] For example, if a man with end stage lung cancer, who was mentally competent and who was under no compulsion, asked his friend who is a nurse, to give him a lethal injection in order to end his life, this will be voluntary euthanasia.

Involuntary euthanasia is a compassionate act to end the life of a patient who is perceived to be suffering and could make a voluntary request, but has not done so.[11] For example, if the same man with end stage lung cancer who wish to live as long as possible were given an overdose of barbiturate without his permission by his friend, the nurse who feel sorry for him, this will be involuntary euthanasia.

NonVoluntary euthanasia occurs when another person, out of compassion, does an action with the intention of ending the life of a suffering patient where the patient is unable to make a voluntary request ( e.g. an unconscious, retarded or demented adult; an infant or child).[12] For example, if a man with advanced Alzheimer’s disease and in great distress had his life taken by her daughter, this would be non-voluntary euthanasia.

“The simple definition of death, acceptable for many generations, is now difficult to accept because new knowledge has forced us to redefine life….. ‘Human life is the ability, actual or in potential, to respond to others or to be self-aware’. Human death is then ‘all other states of organisation or disorganisation’….. it seems best to reserve the idea of death for situations where there is no cerebral response or future possibility of it.”(italics his)[13]

Harvard brain death criteria include 4 major criteria : unreceptivity andunresponsiveness, no movements of breathing, no reflexes and a flat Electroencephalogram (EEG), all persistent over a 24 hour period. This criteria is universally accepted by all medical and legal societies.

Persistent vegetative state is not the same as brain death. Brain death requires the death of the whole brain, including the brainstem. PVS has only lost his or her cortex. The medical problem of PVS after brain damage was first described by Dr.Bryan Jennet and Dr.Fred Plum in 1972.[14]

to the external environment, and the absence of any evidence of functioning mind which is either receiving, or projecting information,

in a patient with long periods of wakefulness. The person in PVS apparently has no contact at all with their external environment.

They are in no sense of the term suffering. According to the definition given by Dr.Vere earlier, such person would be ‘dead’. Yet they are not brain-death as evidenced by their functioning brainstem which controls respiratory and heart functions.

To comment on the quality of this life and to suggest that the person would be better of dead, is to say that we can judge the advantages of non-existence to be greater than the disadvantages of existence.[15] Such a question obviously moves from the realm of medical science into that of faith, religion and metaphysics. It cannot therefore by answered by medical science alone.

Mathers describe three situations which illustrate the problems in determining death and knowing what to do with a patient.

In the first, circulation is maintained by a machine, but there is no evidence of brain activity (flat EEG). In the second, breathing and circulation continue without artificial help, but the cortex is severely damaged and the patient deeply unconscious. In the third, there is prolonged unconsciousness, evident of great cortical damage, and the circulation can only be maintained by machine.

In the first case, the patient is presumed death, in the second alive, and in the third, it is debatable whether the organism is a person, even though biologically there is life.

In the first case where a flat EEG indicates death, a decision to unplug the machine poses no moral dilemmas. The latter two cases involve obvious moral dilemmas. There is biological life, and the criteria for death are not met, but could the individual ever regain consciousness? Is cortical damage too severe to know? In either of the cases, who really knows if the immaterial part has left the body?[16]

Determining death is not as easy as it was used to. And with it comes the dilemma of choosing the adequate medical treatment. James Mathers offer the following guidelines.

If a person is terminally ill (even hooked up to a machine),but according to the best medical opinion would not die within hours or even days, the obligation to preserve life takes precedence. This does not obligate the use of means whose benefit to the patient is dubious. It does mandate not leaving the patient to die without any care and not deliberately killing him. On the other hand, if the patient is terminal, and according to the best medical judgement will die within hours regardless of what is done. Attempts to maintain life at all costs seem tantamount to refusing to accept the fact that it is that person’s time to die. In these cases, allowing the person to die is morally acceptable.[17]

Again one must differentiate between euthanasia which is intending to kill the patient and withholding treatment which may or may not kill the patient. It is morally acceptable to allow a patient, who is considered dying and will not benefit further from any more treatment, to die. It is not acceptable to hasten that death by lethal medications. The differentiation is important.

The Center for Bioethics and Human Dignity in the United States has this definition:

[1] Committee On Medical Ethics, Episcopal Diocese of Washington, D.C. Assisted Suicide and Euthanasia : Christian Moral Perspectives – The Washington Report (Harrisburg, PA : Morehouse Publishing,1997) p.11

[2] Definition of Physician-Assisted Suicide provided by the Christian Medical and Dental Society, USA. Christian Medical & Dental Society Ethical Statement, Physician Assisted Suicide ( http://www.cmds.org/Ethics/4_5.htm )

[3] Policy statements are given in Christian Medical & Dental Society Ethical Statement, Physician Assisted Suicide ( http://www.cmds.org/Ethics/4_5.htm ) and Peter Saunders, Secretary, Christian Medical Fellowship in The Christian Case Against Euthanasia ( http://www.cmf.org.uk/home.htm )

[4] Committee On Medical Ethics, Episcopal Diocese of Washington, D.C. Assisted Suicide and Euthanasia : Christian Moral Perspectives – The Washington Report (Harrisburg, PA : Morehouse Publishing,1997) p.12

[5]Discussion on ‘the distinction between the withholding or withdrawal of medical treatment, and deliberate intervention to end life’. Submission from the Christian Medical fellowship to the Select Committee of the House of Lords on Medical Ethics. ( http://www.cmf.org.uk/home.htm )

[6] Christian Medical & Dental Society Ethical Statement on Euthanasia ( http://www.cmds.org/Ethics/4_6.htm )

[7] Revised Opinion of the AMA Judicial Council, Withholding or Withdrawing Life Prolonging Medical Treatment ( Chicago IL: American Medical Association, 1986)

[8] Christian Medical & Dental Society Ethical Statement on Withholding or Withdrawing of Nutrition and Hydration (http://www.cmds.org/Ethics/4_3.htm )

[9] J.R.Connery, The Ethical Standards for Withholding/Withdrawing Nutrition and Hydration (Issues in Law and Medicine, 1986) 2(2):87-97 quoted in Christian Medical & Dental Society Ethical Statement on Withholding or Withdrawing of Nutrition and Hydration (http://www.cmds.org/Ethics/4_3.htm )

[10] Christian Medical & Dental Society Ethical Statement, Physician Assisted Suicide ( http://www.cmds.org/Ethics/4_5.htm )

[11] Ibid.

[12] Ibid

[13] Duncan Vere,Voluntary Euthanasia – Is There An Alternative? (London:Christian Medical Fellowship Publications, 1971,1979)p. 9-10

[14] B.Jennet,F.Plum, Persistent Vegetative State after Brain Damage : A Syndrome in Search of a Name The Lancet,1971 April 1:734-7

[15] David L.Schiedermayer, The Death Debate (Journal of the Christian Medical and Dental Society, Spring 1992)

[16] James Mathers, “Brain Death” or “Heart Death”? Reflections on an Ethical Dilemma, ExposT87(1976):328 quoted in John S.Feinberg and Paul D. Feinberg, Ethics for a Brave New World (Wheaton, IL : Crossway Books,1993)p.125

[17] Ibid p. 125

[18] Gary P.Stewart et el, Basic Questions on Suicide and Euthanasia: Are They Ever Right? (Grand Raoids,MI: Kregel Publications, 1998)p. 29