Pandemic Letter 29 – Euthanasia

Alex Greenwich MP, the independent member for Sydney, proposes euthanasia in NSW, the Voluntary Assisted Dying Bill 2021.  The Labor Leader of the Opposition, Chris Minns MP, opposes the Greenwich Bill.  The Deputy Premier and Leader of the Nationals, John Barilaro MP, supports euthanasia.  The NSW Legislative Assembly, given the coronavirus pandemic, and given that the Government has the numbers, may not sit any time soon.  If so, the Voluntary Assisted Dying Bill 2021 may be introduced into the Legislative Council.  A key player to watch is Don Harwin MLC, the Leader of the Government in the Legislative Council, and a factional ally of Gladys Berejiklian, the Premier.  If the Voluntary Assisted Dying Bill 2021 is passed in the Legislative Council, the question will be – what then?  What then, Premier Gladys Berejiklian?  What then Health Minister, Brad Hazzard? 

Just as the burden of coronavirus has fallen on ordinary Australians – those living in units, those in casual and insecure employment, the aged, the sick, the disabled – so the burden of euthanasia legislation will fall on the most vulnerable.  Is New South Wales to fall into line with Victoria, Queensland, South Australia, Western Australia, and Tasmania – adopting euthanasia?

Death or a Gastrostomy Tube
To all appearances, my mother was about to die.  Mum was unconscious and largely unresponsive.  She was adopting a foetal position.  Mum had had a stroke. We visited her with the children to say “Goodbye”.

One of the doctors spoke to me, saying even if she survived, she would end up in a nursing home with a gastrostomy tube to provide nourishment.  “Would you want that?  There is an alternative?” said the kindly doctor in the white waistcoat.    

“I want my mother to have ordinary treatment and care, not extraordinary treatment and care”, I responded. 

A day or so later, I went into Intensive Care at 5 am on the way to work.  Mum was, if anything, worse.  I did not expect her to see the day out.  Unfortunately, I had a case which I had not been able to pass.  The case was difficult, the client was difficult, the solicitor difficult, my opponent difficult.  Fortunately, the matter resolved for a figure in mid-range.

Meanwhile, I received a phone call.  Mum was conscious, responsive, sitting up. For some weeks, I went into the hospital early in the morning to feed Mum.  Dad did this each lunchtime and evening.  While Mum had somewhat recovered, she had brain damage.  Mum was transferred to a rehabilitation hospital.  Mum caused consternation by constantly running away!  Eventually, confronted with the suggestion that Mum be placed in a nursing home where she would share a room with three other very disabled persons, Dad brought her home.

For a few weeks things were grim.  Eventually, the doctors got Mum’s medication right.  Dad looked after Mum for almost ten years.  Mum brought much amusement to her grandchildren!  Mum engaged in unconventional behaviour which would have been unthinkable before the stroke.  Mum brought our family together.


Tragic Situation 
In any discussion of euthanasia, a preliminary must be to acknowledge there can be circumstances where a spouse of many years, the spouse often elderly, disabled, or at least unwell, overwhelmed by the sickness or disability of his or her husband or wife, not motivated by malice but by a false compassion, either kills the husband or wife, or assists in the husband or wife’s suicide.  In such circumstances, the police properly may exercise a discretion not to charge the spouse.  The Director of Public Prosecutions may properly exercise the discretion not to prosecute.  A custodial sentence should not be imposed:  R v Mathers [2011] NSWSC 339.  This is a tragic situation, in which the law protecting human life, can be upheld whilst taking into account the particular circumstances. Quite different is the proposal to legislate for euthanasia.

A second preliminary is to recognise the importance of intention.  The Catechism of the Catholic Church #2279 declares: “The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only foreseen and tolerated as inevitable.”  A patient may die sooner than they would otherwise, but this is not a reason for withholding pain relief as long as the doctor acts in accordance with responsible medical practice with the objective of relieving pain or distress, but with no intention to kill.  The doctor’s intention, and evaluation of the pain and distress suffered by the patient, are crucial in judging the double effect.  If the intention is the relief of pain or severe distress, and the treatment is appropriate to that end, then the possible double effect is no obstacle to such treatment being given.  What one foresees as probable or even certain to result from one’s actions need not be what one intends.  So, the moral argument which condemns euthanasia as intentional killing does not condemn the use of drugs which advance death as a side-effect. 

A third preliminary is to acknowledge that we all have to die.  Most of us will see our parents die, many of us our spouse, some of us our children, all of us some friend or colleague.  Extraordinary measures to prevent the death of a very old or sick or disabled person may not be appropriate.  We are bound to take ordinary measures, but more important is to see God’s providence at work, giving the dying person every opportunity to attend to their affairs, to make peace with God, forgiving all those who may have wronged them, asking forgiveness of any whom they may have wronged, dying in a prayerful manner, offering up whatever discomfort or pain in union with Our Lord on the Cross for the good of all, especially those most in need, and those closest to them.  There is an ars moriendi which we each must learn.

Practical Considerations

To my mind, there are five considerations to keep in mind when considering the Greenwich euthanasia proposal.

Slippery Slope 
First, wherever euthanasia has been legalised, the grounds are eventually widened to include involuntary killing.  The slippery slope involves increasing numbers of people who are killed, widening categories of people who are killed, a drift from voluntary to non-voluntary.  Once the prohibition of intentional killing is crossed, there is no turning back. The advocates for euthanasia often see an initial restrictive law as a first step to amendments authorising increasingly broad killing.

Adverse Incidents 
Second, at a time when there is a high rate of adverse incidents in Australian hospitals, this is not the time to be introducing euthanasia.  Anyone who thinks going to hospital is safe should read the Australian Institute of Health and Welfare, Australia’s Health 2016.  In 2013/2014, 9.9% of hospitalisations in public hospitals, and 6% in private hospitals involved a hospital acquired condition.  Things go wrong for many reasons, and, if hospitals are to become institutions for deliberate killing, things will go wrong in a fashion which cannot be remedied.

The Grattan Institute’s Report All Complications Should Count:  Using Our Data to Make Hospitals Safer February 2018 says one in every nine patients who go into hospital in Australia suffers a complication – about 900,000 patients each year.  A patient’s risk of developing a complication varies dramatically depending on which hospital they go to.  In some cases, the additional risk of a complication at the worst-performing hospitals can be four times higher than at the best performers.

Introducing a system of intentional killing of vulnerable patients into a hospital system where there are large numbers of adverse events, and inadequate data as to those events, will have unpredictable, and unfortunate consequences for the overall quality of patient care.

Third, most of us are at our most vulnerable when we are sick or dying.  Despite the so-called safeguards in the Voluntary Assisted Dying Bill 2021, there is little adequate attempt to ensure death is truly sought.  Depression and anxiety, which are often an accompaniment of sickness, are ignored.  The safeguards will be administered by doctors who may be tired of the demands of a particular patient, or worse euthanasia zealots, assisted by a colleague who, in reality, exercises no independent judgment, unchallenged by a family who are provided with no real information, deferential to the “authority” of doctors, exhausted with the demands on their time made by the sick or dying person.  Privacy may be used as a means of ensuring no real scrutiny of what is a failure of care. Euphemistic language oils the process. Tick and flick! Doctors bury their mistakes, and their failure to provide the sick or dying person and the person’s family with appropriate support. The bureaucracy created to scrutinise euthanasia legislation may well be staffed by pro euthanasia enthusiasts. Doctors and institutions who conscientiously object to killing patients will be shunted aside, or leave for areas of medicine or care where they are not required to do what they abhor. Euthanasia is an assault on the most vulnerable at their most vulnerable.

Hippocratic Oath 
Fourth, the Hippocratic objection to killing should stand: “And I shall give to no one a deadly medicine if asked to do so, neither shall I give advice to that effect.” The Voluntary Assisted Dying Bill 2021 will alter the culture of doctors and nurses, the culture of medical, aged and disability care.  Unexpressed distrust will alter the relationship with the patient. Patients will be reluctant to see a doctor, go into hospital, go into care. The euphemisms which are the accompaniment of euthanasia will drive out confidence, and sow scepticism.

Hard Cases 
Much of the argument for the Voluntary Assisted Dying Bill 2021 depends on hard cases, catastrophic situations, with a restricted “assembly” of facts, narrowing of the lens, a restricted view which leaves important considerations out.  Left out of consideration is the danger of creating a culture hostile to human life; emphasising the individual, disregarding that person’s role as a member of a family; allowing no room for practical compassion, no room for solidarity with the aged, the sick and disabled; seeing little value in the lives of persons who are regarded as not contributing to the economy, motivated only by utilitarian considerations.

Catholic Perspective

The Catholic Church is one of the most consistent opponents of intentional killing – at the beginning of life, at the end of life, in war, and now, by way of capital punishment.  Most other religious groups including Christians, Jews and Muslims also oppose euthanasia. Yet some suggest that support for euthanasia is consistent with Christian faith and practice. The weasel words of “dying with dignity”, “autonomy”, “the right to die”, “compassionate choice”, “assisted dying”, “unbearable suffering”, “quality of life”, “empathy”, “choice”, “hope”, “empathy”, “common sense”, “a good death”, “the right to decide”, “pro choice”, “undignified death” are used imprecisely, and without sufficient analysis, to justify killing.

Declaration On Euthanasia 
Perhaps the most succinct statement of the Catholic position on euthanasia is the Sacred Congregation for the Doctrine of the Faith’s Declaration on Euthanasia approved by St John Paul II in 1980.

Bureaucratization of Death  
The Declaration was released at a time when medical science was prolonging the time and place of death, particularly in developed economies.  Today, most of us can expect to die in our 80’s, rather than much earlier, as in past generations.  Most of us will die in hospital, in a hospice or aged care facility, rather than at home.  Professionals who have had no prior contact with the seriously ill person tend to control the dying process.  The family doctor is no longer a player.  Utilitarian perspectives dominate hospital administration.  Doctors and nurses have little time simply to “talk” to their patients. Palliative care is too often a Cinderella of medicine.

Cultural Change 
Cultural changes are impacting attitudes to human suffering and death.  A significant world view sees God as dead, or practically dead, as having no impact on how we live our lives.  People tend to be very individualistic.  The fragile family with successive couplings and de-couplings deprives many children of a father – who simply disappears from the lives of his children.  Many old people have little or no contact with their children and other family members.  Very often older people are segregated so that their interaction with younger people is formal, and fleeting, rather than personal and deep.  Retirement is seen as relentless pleasure seeking, rather than as a time to contribute to the good of others, especially children and grandchildren.  In an ever-busier society, with both spouses working, often travelling long distances, living far away from work, fewer have time for parents and grandparents.  Voluntary associations which provide companionship, and which engage in civic and charitable activities, are withering.  Everyone is just too busy. There is a loss of sense of just how mutually dependent we are.  Moreover, the autonomy claim that we have the right to determine what is done to us, to decide as to our own medical treatment, is difficult to dispute.

Killing As a Solution
Germain Grisez and Joseph Boyle, writing in the late 1970’s, commented on the phenomenon of mass killing, both in war, and by utopian regimes, such as Mao-Tse Tung’s China, hoping to create a “perfect society”, a phenomenon of the 20th century:

… For modern, post Christian thinkers, mass killing is acceptable as a final solution to human problems.  Human life in itself no longer has sanctity.  What is important is the quality of life, to the extent to which an individual’s life contributes instrumentally to the attainment and enjoyment as specifically human and personal values.  Whenever some human individual’s life is not of sufficient quality – whether measured from the individual’s own perspective or from the perspective of society or both – that life becomes a disvalue.  Such a life is unwanted because it is useless; it is evil because it is unwanted; it must be destroyed because it is evil. 

By contrast, Christians have a perspective on human life summed up in St Paul’s words – “If we live, we live to the Lord, and if we die, we die to the Lord” (Romans 14:8). Even for those who are not Christians, but who acknowledge human dignity, and universal human rights, the push for euthanasia is of concern.

Basis of All Goods  
As to the value of human life, the Declaration on Euthanasia makes three points.  First, human life is the basis of all goods.  Human life is a gift of God’s love, which we are called upon to preserve and make fruitful.  No one can make an attempt on the life of an innocent person, without violating a fundamental right, and therefore without committing a crime of the greatest gravity.  Second, everyone has the duty to lead his or her life in accordance with God’s plan. That life is entrusted to the individual as a good that must bear fruit already here on earth, but which finds its full perfection only in eternal life.  Third, intentionally causing one’s death, or suicide, is equally as wrong as murder. Such an action on the part of a person is to be considered as a rejection of God’s sovereignty and loving plan.  Furthermore, suicide is often a refusal of love for self, the denial of the natural instinct to live, a flight from the duties of justice and charity owed to one’s neighbour, to various communities or to the whole of society – although at times there are psychological factors present that can diminish responsibility or even completely remove it.

Mercy Killing  
Etymologically, “euthanasia” originally meant an easy death without severe suffering.  Today, euthanasia is used in a more restricted sense to mean an act or omission which of itself and by intention causes death, in order that all suffering may be eliminated. Euthanasia is characterised by the intention to kill.   The method used is directed to the death of the person. 

By reason of prolonged and barely tolerable pain, for deeply personal or other reasons, people can be led to believe that they can legitimately ask for death or obtain it for others.  Although in these cases the guilt of the individual may be reduced or completely absent, the error of judgment into which the conscience falls, perhaps in good faith, does not change the nature of this act of killing, which will always be in itself something to be rejected.  The plea of a gravely ill person who asks for death is almost always an anguished desire for help and love.  What a sick person needs, beside medical care, is love, the human and supernatural warmth with which the sick person can, and ought be surrounded by all those close to him or her, parents and children, doctors and nurses.

Normal Means  
The Sacred Congregation for the Doctrine of the Faith says, confronted by grave illness, it is permissible to make do with the normal means that medicine can offer. One cannot impose on anyone the obligation to have recourse to a technique which carries a risk or is burdensomeSuch a refusal is not the equivalent of suicide.  On the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community.  When inevitable death is imminent in spite of the means used, it is permitted in conscience to take the decision to refuse forms of 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.  

According to the Congregation, life is a gift of God, and, on the other hand, death is unavoidable.  It is necessary therefore that we, without aiming to hasten the hour of death, should accept it with full responsibility and dignity.  It is true that death marks the end of our earthly existence, but at the same time, it opens the door to immortal life.  Therefore, all must prepare themselves for this event in the light of human values, and Christians even more so in the light of faith.

Evangelium Vitae 
St John Paul II, in his encyclical Evangelium Vitae: the Gospel of Life (1995), asks, How should one act in the face of death?  The believer knows that human life is in the hands of God.  In moments of sickness, we are called to have trust in the Lord and to renew our Faith in the one who heals all diseases.  The mission of Jesus, with the many healings he performed, shows God’s great concern for bodily life.  Nevertheless, the life of the body in its earthly state is not an absolute good for the believer, especially as one may be asked to give up life for a greater good.  No one can arbitrarily choose whether to live or die.  The absolute master of such a decision is the Creator alone, in whom we live and move and have our being.

Thou Shalt Not Kill 
The truth of life is revealed by God’s commandment, “Thou shalt not kill”. The entire Law of the Lord serves to protect life, because it reveals that truth in which life finds its full meaning.  The new heart which believers receive makes it possible to appreciate the deepest and most authentic meaning of life, namely, that of being a gift which is fully realized in the giving of self.  In the contemplation of the spectacle of the Cross, we find the complete revelation of the whole Gospel of Life. On the Cross God’s glory is made manifest. Life finds its centre, its meaning and fulfilment when it is given up.

If the Declaration on Euthanasia is a succinct consideration of euthanasia from the perspective of moral theology, Evangelium Vitae adopts a broader and deeper theological perspective.

Culture of Death 
St John Paul II writes of a “culture of death”, above all in prosperous societies, marked by excessive preoccupation with efficiency which sees the growing number of elderly and disabled people as intolerable and burdensome. Elderly and disabled persons are very often isolated by their families, and by society, which is organised on the basis of criteria of productive efficiency, according to which a hopelessly impaired life no longer has any value.

Forgoing Treatment 
Euthanasia is to be distinguished from the decision to forgo so-called “aggressive medical treatment”, a medical procedure which no longer corresponds to the real situation of the patient, because either it is disproportionate to any expected results, or because it imposes an excessive burden on the patient and his family.  Sometimes relatives unreasonably demand that “everything” be done.  It needs to be determined whether the means of treatment available are objectively proportionate to the prospects for improvement.  To forgo extraordinary or disproportionate means is not the equivalent of suicide or euthanasia.  This rather expresses the acceptance of the human condition in the face of death.  It may be licit to relieve pain by narcotics even if the result is decreased consciousness and shortening of life. St John Paul II qualifies this by stating, as they approach death, people ought be able to satisfy their moral and family duties, and to prepare in a fully conscious way for their definitive meeting with God.

St John Paul II solemnly confirms that euthanasia is a grave violation of the law of God. No one can be in any doubt that support for euthanasia is inconsistent with being a faithful Catholic.

Samaritanus Bonus 
In 2020, the Congregation for the Doctrine of the Faith released, with the approval of Pope Francis, the letter, Samaritanus Bonus:  On the Care of Persons in the Critical and Terminal Phases of Life.  As is evident from its title, the perspective of this document is care for the dying person.  Samaritanus Bonus considers various controverted questions – nutrition and hydration, care for the newborn who are likely to die, analgesic therapy and loss of consciousness, vegetative state, pastoral discernment towards those who request euthanasia or assisted suicide. 

Conscientious Objection
One issue which may become increasingly significant is conscientious objection on the part of healthcare workers and healthcare institutions.  Formal or immediate material cooperation with euthanasia must be excluded.   It is never morally lawful to collaborate with immoral actions.  Samaritanus Bonus refers to what St John Paul II had to say:

“Christians, like all people of good will, are called, with a grave obligation of conscience, not to lend their formal collaboration to those practices which, although allowed by civil legislation, are in contrast with the Law of God. In fact, from the moral point of view, it is never licit to formally cooperate in evil. This cooperation occurs when the action taken, either by its very nature or by the configuration it is assuming in a concrete context, qualifies as direct participation in an act against innocent human life, or as sharing the immoral intention of the principal agent. This cooperation can never be justified neither by invoking respect for the freedom of others, nor by relying on the fact that civil law provides for it and requires it: for the acts that each person personally performs, there is, in fact, a moral responsibility that no one can ever escape and on which each one will be judged by God himself.”

Very relevant to the Greenwich Voluntary Assisted Dying Bill 2021 is the comment in Samaritanus Bonus that, an institution’s collaboration with other hospital systems is not morally permissible when it involves referral for persons who request euthanasia.  Are the supporters of the Greenwich Bill so ideologically committed that they are willing to put the NSW hospital and aged care system at risk by steam-rolling those who in good conscience will not support euthanasia?

The Church’s consistent rejection of euthanasia derives from the Judaeo-Christian tradition to be found in the Bible, in particular, the Ten Commandments which uphold human dignity, reaffirmed in Sermon on the Mount.

What is at stake in killing is the person, as Genesis says, made in the image and likeness of God. The ancient account of Cain who in anger kills his brother Abel exemplifies the prohibition against killing, but the prohibition against killing Abel  just as much to anyone who contemplates killing the murderer Cain. The Egyptian Pharaoh who commands the killing of the baby Hebrew boys, and Herod the Great who murders the male children of Bethlehem two of age or less are counter examples.  As God told Noah, human life is to be propagated – “be fruitful and multiply, bring forth abundantly”. Solomon the psalmist sees happiness in the birth of children.  As the psalmist King David says – “Yet you have made him little less than the angels, and you have crowned him with glory and honour.”  Elsewhere King David, in another psalm, sees the unborn child as coming from God.  The Second Commandment, “Love your neighbour as yourself”, epitomises human dignity. The parable of the Good Samaritan emphasises the universality of human dignity. So laws which derogate from human dignity elicit the response – “We must obey God rather than men”. 

As Archbishop Anthony Fisher OP, writing as a scholar rather than as a bishop, has argued, in imitation of Christ’s resignation and trust, His obedience and sense of belonging to God, Christians can (and do) pray that God’s will be done, even when they would rather the cup of suffering be taken from them. 

Greenwich Bill

Alex Greenwich’s Voluntary Assisted Dying Bill 2021:

  • says nothing about palliative care.  
  • masks its intentions in euphemism.  
  • rebrands deliberate and intentional killing as voluntary assisted dying. Section 87(6) mandates that a medical practitioner must not include a reference to voluntary assisted dying in the cause of death certificate.  
  • ignores the reality that, given the plasticity of medical opinion, anything is possible as regards medical certification.  Apparently complex procedures become perfunctory in the hands of those who have an interest in ridding themselves of challenging patients, and in the hands of zealots.
  • fails to recognise that persons who are seriously ill are particularly vulnerable, and that patients are usually members of a family who value them for themselves.  
  • shuts the sick person’s family out of decision-making.  
  • makes no sufficient protection for persons who may be depressed or anxious.  
  • makes no adequate provision to respect institutions committed to the care of the aged, the disabled and the sick, whose ethic of care is inconsistent with cooperation in intentional killing.  Part 5 of the Bill compels residential facilities, health care establishments to cooperate in intentional killing.
  • changes the culture of medical, hospice and aged care from compassion to intentional killing. Patients will be reluctant to commit themselves to situations where they may be killed.

The choice for Premier Gladys Berejiklian and Health Minister Brad Hazzard, and other members of the NSW Parliament, is whether they will support a Bill which is destructive of human beings; a Bill which is destructive of care and compassion; destructive of law; which sews distrust in the minds and hearts of the vulnerable, the poor, the sick and disabled, those who are alone; which opens a door to opened ever wider; a step backwards, a step into chaos, and disregard for human rights.

Michael McAuley
27 August 2021