The Slippery Road to Euthanasia

After considering euthanasia and suicide from a biblical-theological perspective and also from an ethical perspective, let us now approach the subject from a historical-traditional one. The historical-traditional perspective will be mainly from a Judeo-Christian point of view. Other cultures generally have not held such distinctly high views of human life and the idea of man and woman, based on divine revelation rather than natural revelation, contingencies and expedience. Such cultures as Islam ( which comes after Christianity ) and later modern Hinduism share some of the Judeo-Christian traditions on the subject because of the influence of the Judeo-Christian tradition[1]. Judeo-Christian tradition was a ‘global’ tradition at one time because of colonialism and imperialism.

Suicide, euthanasia, infanticide and abortion were all widely practiced in the ancient Greco-Roman world but suicide mostly amongst the elite. There was no dishonor associated with suicide. It was forbidden for slaves to take their own lives, as they are the property of their owners.[2] Philosophers that argued against suicide are Aristotle and Plato who based their arguments on natural laws. Aristotle’s objection is economic and political. The attainment of the human form is of great moral significance; the destruction of human life at any stage was thus naturally morally offensive. In committing suicide a person was also committing an offence by robbing the State of one’s civic and economic contribution. Plato’s objection was more metaphysical and religious. Plato’s view was that ‘we did not create ourselves, we are property of the gods; it is therefore presumptuous of us to desert our station before being relieved.’[3] It appears that Plato’s and Aristotle’s views of suicide are exceptions rather than the rule though they have significant influence later on.

Typical of the ancient views of suicide and euthanasia were that of Seneca, a Roman philosopher:

Against all injuries of life I have the refuge of death. If I can choose between a death of torture and one that is simple and easy, why should I not select the latter? As I choose the ship in which I sail and the house in which I inhabit, so I will choose the death by which I leave life. In no matter more than in death should we act according to our desire…….Why should I endure the agonies of disease when I can emancipate myself from my torments.[4]

Edward Larson and Darrel Amundsen wrote in their study of suicide and euthanasia in classic antiquity the following conclusion:

1. There is no evidence of any train of ancient pagan thought and values that endorsed suicide as always appropriate and proper for anyone desiring to die under any and all circumstances with no qualifications, restrictions or limits.

2. It is highly questionable that any train of ancient pagan thought and values condemned all suicides irrespective of individual circumstances. Pythagoreanism and some strains of Platonism were possible exceptions.

3. There is scant evidence that any train of ancient pagan thought and values condemned suicide by the hopelessly ill. Again Pythagoreanism[5] and some strains of Platonism were possible exceptions.[6]

They conclude: “there is a plethora of evidence for the practice of euthanasia and physician-assisted suicide in the classical world. But evidence for those who held that a physician should not be involved in such activities is painfully scarce”.[7]

In ancient Judaism, suicide is a serious crime. The Hebrew phrase pikku’ah nefash means “regard for human life.” It is used in rabbinical literature to express the duty to save human life (The life of a fellow Israelite) when it is in peril, which is one of the most sacred obligation in Judaism. This obligation included the sacred duty to preserve one’s won life under most circumstances.[8] Josephus tells us that the body of a suicide was not buried until after sunset and then carried to the grave without the normal funeral rites.[9]

In the entirety of Jewish literature from the Old Testament through the fifth century A.D., we know of not one case of a Jew taking his own life or having someone kill him in order to escape from illness. There is only one instance of which we are aware of anyone in the sources attempting suicide when he was ill, and that was Herod. According to Josephus, when Herod the Great was nearing death, “he was so tormented by lack of food and a racking cough that his sufferings mastered him and he made an effort to anticipate his appointed end. He took an apple and asked for a knife, it being his habit to cut up apples when he ate them; then looking round to make sure there was no one to stop him, he raised his hand to stab himself. But his cousin Achiab dashed up and stop him by grasping his wrist.”[10]

The early church took over many of the Jewish traditions in its attitude towards human life, suicide and euthanasia. It is not surprising to find that the early church fathers did not write much about it. The issue was more of martyrdom. Some Christians took to flaunting their faith as a way of courting their own martyrdom. This came to be frowned upon and the church accepted the position enunciated by Clement of Alexandria (ca. 155- ca. 220) that honoured martyrdom proper but stressed the importance of doing all one could, short of betraying one’s faith to avoid it.[11]

Eusebius is the earliest church father to record any examples of Christians committing suicide. They were those (1) who killed themselves to avoid being arrested and tortured, (2) who had already being arrested but dramatically ended their lives before being executed, and (3) virgins and married women who committed suicide to avoid rape.[12]

There was no known reference in the patristic texts for suicide by the ill in the Christian community[13]. Christianity did introduce a new concept into the Greek and Roman world on antiquity – an obligation to care. Not an obligation to cure- but an obligation to care – a categorical imperative to extend compassion in both words and deeds to the poor, the widowed, orphans and the sick. This was a truly revolutionary concept and we still feel its influence today.

It was Augustine who formalized and consolidated traditional Judeo-Christian opposition to suicide and euthanasia as an unacceptable form of murder. In Book 1 of the City of God, he outlined his defense of the traditional position:

He also denounced it as a cowardly way of escaping the pain and suffering of this life.[15]

Thomas Aquinas in his Summa Theologiae expressed the classical objection to suicide, arguing that it was absolutely prohibited because (1) it violated our natural self-love and inclination to preserve our being, (2) it offended the human community, of which each human being is a part, and (3) it offended God, who offers life as a gift.[16]

Aquinas was deeply impressed by the view of the Jewish scholar Maimonides that killing an innocent person, “whether he is healthy or about to die from natural causes”, is wrong. Euthanasia for those in pain and suffering, Aquinas maintained, was contrary to Christian tradition, natural law, and the well being of society. It violated the dominion of God over human life. Aquinas spelled out is some detail the Christian position that the only justification for taking the life of another is to protect innocent life. Three circumstances in which killing may be allowed are (1) self-defence, (2) the defence of innocent from an unjust aggressor in war, and (3) the defence of society in the case of capital punishment.[17]

The continuation of the ancient Christian prohibition of suicide into Medieval Christianity was extraordinary effective. What is striking about the history of suicide in the Middle Ages is that there were few notable suicides between 400 and 1400 A.D. among the orthodox Christians. Catholic doctrines and attitudes had so permeated society during this era that individuals did not find suicide to be an efficient means of resolving personal, financial or political issues.[18]

The only reference to euthanasia in the period of the late Middle Ages that Larson and Admundsen found in their research was in a plague treatise written by physician Sigmund Albichs in 1406: “The….physician should refrain fromadministering anything to the patient that will cause him to die quickly, for then he would be a murderer.”[19]

By the sixteenth century, some Christians explicitly discussed suicide and euthanasia in the face of illness. In an imaginary land named Utopia depicted by Thomas Moore, a Roman Catholic, suicide and euthanasia were encouraged for those suffering from incurable diseases accompanied by continuous pain. Speculation that the book provides satire, rather than serious argument for suicide and euthanasia is supported by the fact that as Moore awaited his own execution in the tower of London, he wrote A Dialogue of Comfort : Against Tribulation, in which he argues against these acts.[20]

John Donne, the English poet and Anglican priest, wrote the first defence of suicide in English in Biathanatos. There he defined suicide very broadly to include all cases of willing death, including Christ’s death on the cross. Donne did not permit suicide undertaken for self interest however.[21]

Neither Martin Luther, the great Reformer who endured great physical suffering due numerous health problems[22] and John Calvin, who was in fragile health, approved of euthanasia as a means of ending the misery brought on by illness. Both viewed sickness as an opportunity for gaining increased confidence in God’s presence and power, and thus bringing about spiritual healing.[23]

In the ars moriendi, or the art of dying literature, the recommendation to thosecaring for the dying was to provide ease and comfort, rather than to cause their death. Works such as The Rule and the Exercise of Holy Dying by renown Anglican Bishop Jeremy Taylor explained the importance of preparing for death, and maintained that we should not choose our cause of death.[24]

During the eighteen century, Christian dominance over Western thought and ethics was weakened by the successes of the scientific revolution in offering rational,empirical explanations for natural phenomenon. The ‘Age of Reason’ has begun. Reasons and experience become more important than divine revelation. To many philosophers, individual freedom and autonomy became the rightful objectives of human society. They also reviewed the current thinking on suicide.

The leading apologists for suicide are the English philosophers such as David Hume and John Locke. They drew opposing fire from the Roman Catholic Church, Bishop of Norwich, John Wesley and Isaac Watts. The Christian orthodoxy remained firm in their opposition to suicide.However, from the early 20^th century onwards, it was noted that “despite firm legal restrictions against assisted suicide and euthanasia that remained largely unchanged during the nineteenth and twentieth centuries, the judicial system tended to exhibit increasing leniency if the victim was terminally ill or severely incapacitated.”[25]

The movement to legalise euthanasia, which had grown within some liberal and religious circles in the United States during the 1920s and 1930s gathered momentum around the 1950s. Joseph Fletcher, the popular liberal ‘Situation Ethics’ proponent, published a defence of voluntary euthanasia in 1954. His ideas immediately encountered opposition from Karth Barth, Paul Ramsey and Carl F.H. Henry. Opinion surveys, one of which showed growing popular support for both eugenics and euthanasia based largely on response to individually compelling cases, reversed direction as Americans began to realise how Nazi Germany had applied such concepts as a general practice.[26]

This was accompanied and reinforced by subsequent ‘pro-life’ (such as abortion) and ‘moral majority’ and new, reactionary conservative movements.Leo Alexander, a psychiatrist who worked with the office of the Chief of Council of War Crimes at Nuremberg quoted :

“The beginning at first was merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the attitude, basic in euthanasia movement that there is such a thing as a life not worthy to be lived. This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-German. But it is important to realize that the infinitely small wedged-in lever from which this entire trend of mind received its impetus was the attitude toward the non rehabitable sick” [27]

In the progression to euthanasia, Peter Saunders argued four factors must be present. They are, (1) favourable public opinion, (2) a group of willing doctors, (3) economic pressure, and (4) a law allowing it.[28] These factors reflects a progressive decline of religious authority and its isolation and separation from the public arena.

In 1974, the movement and debate on euthanasia was brought to dramatic focus in the United States by Karen Ann Quinlan. After taking a dangerous mix of hallucinatory drugs and alcohol, Karen went into a coma and was dependent on a ventilator, Seven months later, her father requested that the ventilator be turned off. The hospital refused and the father went to court. In 1976, the New Jersey Supreme Court issued a landmark decision that Quinlan has a constitutional right to die. The ruling gained added force when the United States Supreme Court declined to review it. The case received a lot of publicity and sympathy from the public and the public began to perceive that euthanasia might be a viable option.

As the result of the Nuremberg trials, the early post-war period saw the adoption of two highly significant ethical declarations by the World Medical Association. The first of these, the Declaration of Geneva, included the following affirmation: ‘I will maintain the utmost respect for human life from the time of conception; even under threat I will not use my medical knowledge contrary to the laws of humanity’. The second of these is the International Code of Medical Ethics which affirmed that ‘a doctor must always bear in mind the importance of preserving human life from time of conception until death’

Since 1948, there has been a gradual escalation of ‘therapeutic abortions’. In 1970, the World Medical Association adopted the Declaration of Oslo which established the precedent for ‘therapeutic abortion’ in circumstances where ‘the vital interests of the mother conflict with those of the unborn child.’ During the 35^th World Medical Assembly in Venice October 1983, the words ‘from the time of conception until death’ were changed to ‘from its beginning’ thus begging the question of when human life begins.

Amendments to the International Code of Medical Ethics were even more radical. The words ‘from the time of conception until death’ were excised and the new version read ‘A physician must always bear in mind the obligation of preserving human life ‘. Neither the time at which human life begins nor the time it ends was defined but presumably left open to ‘individual conviction and conscience which must be respected’.[29] Hence the discussion moved from the beginning of life to the end of life as the medical fraternity relaxed its rulings, first on abortion and then the end of life period. When the battle against abortion was lost, the journey towards euthanasia began.

Another important issue is a purely pragmatic and economic one : the escalating cost of healthcare.

The raw figures are staggering. Between 1960 and 1995 heath spending in the United States has increased at more than twice the rate of inflation and now consumes nearly 15 percent of the nation’s gross national produc ……..The government spent $176 billion in Medicare in 1996…And payments [government spending on Medicare] are predicted to rise dramatically in the coming years, up at least 50 percent in 2001…Much of this federal spending and private dollars goes for end-of-life treatment…..One out of every twelve dollars spent on healthcare in the United States pays for intensive-care Treatment, and nearly 30 percent of all Medicare payments are attributable to patients in their last year of life.[30]

Because of escalating healthcare costs, many insurance companies, health care managers, organisations and governments are pushing for pro-euthanasia measures today.

In this brief historical survey of the trend towards euthanasia, we have seen that initially in the Greco-Roman world, suicide and euthanasia were acceptable. Only in ancient Judaism was it specifically forbidden. The early Christians carried forth this tradition of forbidding suicide and euthanasia through the Middle Ages and beyond to the period of Reformation. With the ‘Age of Reason’ in the 18^th and 19^th Century, Judeo-Christian thinking began to lose some of its influence. In the early 20^th Century, society began to boldly question the traditional thinking about suicide and euthanasia. Sensational cases reported by the press swayed public opinion while the relaxation of rulings against abortion weakened the belief in the sanctity of life. With the increasing costs of healthcare, the die was cast for in favour of euthanasia under appropriate conditions. Though this was not without continuing resistance from Christians and mainstream religious circles and pro-life movements.

[1] Harold G.Coward, Julius J. Lipner and Katherine K.Young, Hindu Ethics: Purity, Abortion and Euthanasia ( New York : State University of New York ). The authors argue that British policies and laws have influenced modern Hinduism.

[2] Russell Blacker, Suicide Down the Ages: A Judeo-Christian Perspective ( Christian Medical & Dental Society http://www.cmds.org/Ethics/4_4_2d.htm )

[3] Ibid

[4] Quoted in Francis J. Bechwith and Norman L. Geisler, Matters of Life and Death (Grand Rapids, MI : Baker Book House, 1991)p. 158

[5] The Pythagoreans, who were alleged to be instrumental in formulating the Hippocratic Oath. Contrary to popular belief, the Pythagoreans were a small group whose tenets include belief in reincarnation, the practice of vegetarianism and sexual purity, and a condemnation of abortion, suicide and the shedding of blood. They were unlikely to be of any great influence in their society.

[6] Edward Larson is professor of history and law at the University of Georgia. Darrel Amundsen is professor of classics and chair of the department of modern and classical languages at Western Washington University, Washington. He is a recognised expert in the field of ancient and medieval medical history and ethics. See Edward J. Larson & Darrel W.Admundsen, A Different Death : Euthanasia and the Christian Tradition (Downers Grove,IL: InterVarsity Press, 1998 ) p. 32-33

[7] Ibid p. 35

[8] Ibid p. 58

[9] Russell Blacker, Suicide Down the Ages: A Judeo-Christian Perspective ( Christian Medical & Dental Society http://www.cmds.org/Ethics/4_4_2d.htm )

[10] Edward J. Larson & Darrel W.Admundsen, A Different Death : Euthanasia and the Christian Tradition (Downers Grove,IL: InterVarsity Press, 1998 ) p. 55

[11] Russell Blacker, Suicide Down the Ages: A Judeo-Christian Perspective ( Christian Medical & Dental Society http://www.cmds.org/Ethics/4_4_2d.htm )

[12] Edward J. Larson & Darrel W.Admundsen, A Different Death : Euthanasia and the Christian Tradition (Downers Grove,IL: InterVarsity Press, 1998 ) p.114

[13] Ibid p. 101

[14] Ibid p.121

[15] Committee on Medical Ethics, Episcopal Diocese of Washington, Assisted Suicide and Euthanasia : Christian Moral Perspectives, The Washington Report (Harrsburg, PA: Morehouse Publishing, 1997)p.24

[16] Ibid p.24

[17] p.26

[18] Barry, “The Development of Roman Catholic Teachings on Suicide,”p.473-74 as quoted in Edward J. Larson & Darrel W.Admundsen, A Different Death : Euthanasia and the Christian Tradition (Downers Grove,IL: InterVarsity Press, 1998 ) p. 132-133

[19] Edward J. Larson & Darrel W.Admundsen, A Different Death : Euthanasia and the Christian Tradition (Downers Grove,IL: InterVarsity Press, 1998 ) p.155

[20] Committee on Medical Ethics, Episcopal Diocese of Washington, Assisted Suicide and Euthanasia : Christian Moral Perspectives, The Washington Report (Harrsburg, PA: Morehouse Publishing, 1997)p.25

[21] Ibid p.25. Also see Edward J. Larson & Darrel W.Admundsen, A Different Death : Euthanasia and the Christian Tradition (Downers Grove,IL: InterVarsity Press, 1998 ) p.151. John Donne wrote Biathanatos before he became an Anglican priest and while he was still struggling with his own salvation.

[22] Luther had heart problems, kidney and bladder stones, an ulcerated led, severe constipation and haemorrhoids, migraine headaches, depression and recurrent respiratory problems.

[23] Committee on Medical Ethics, Episcopal Diocese of Washington, Assisted Suicide and Euthanasia : Christian Moral Perspectives, The Washington Report (Harrsburg, PA: Morehouse Publishing, 1997)p.27

[24] Ibid p.27

[25] Edward J. Larson & Darrel W.Admundsen, A Different Death : Euthanasia and the Christian Tradition (Downers Grove,IL: InterVarsity Press, 1998 ) p.161. In the 1920s and 1930s, in much highly publicised criminal prosecution against family members or physicians for euthanasia, the juries refuse to indict or convict or the judges suspend the sentence of those convicted.

[26] Ibid p.164

[27] Leo Alexander, Medical Science Under Dictatorship ( New England Journal of Medicine, 1949) 241: 39-47

[28] Peter Saunders, The Christian Case Against Euthanasia ( Christian Medical fellowship http://www.cmf.org.uk/home.htm )

[29] Peter Saunders, The Christian Case Against Euthanasia ( Christian Medical fellowship http://www.cmf.org.uk/home.htm )

[30] Edward J. Larson & Darrel W.Admundsen, A Different Death : Euthanasia and the Christian Tradition (Downers Grove,IL: InterVarsity Press, 1998 ) p.171-172