Euthanasia

In the Henry Cooper Lecture for 1997 Professor Robin Gill speaks of the challenge to the Churches of changing attitudes towards euthanasia.


This is the text of the Henry Cooper Lecture for 1997. Extracts from it were published in the Autumn 1997 issue of Chrism. The author's profile below is from the same date

The Revd Canon Robin Gill is Michael Ramsey Professor of Modern Theology at the University of Kent. He has had a distinguished academic career, having previously held posts in both Edinburgh and Newcastle Universities. In spite of heavy demands from his academic work he still at the time managed to practise as a parish priest, taking responsibility for several parishes in Scotland and the Borders. He has published a number of books, including 'A Textbook of Christian Ethics', and is a regular contributor to several periodicals.

Guild of St Raphael

A Matter of Life and Death

How should Christians respond to increasing calls in many parts of the world for the legalisation of euthanasia? In the Netherlands euthanasia is now de facto legal and only some churches there have been hostile to this. The agreement of the judiciary there not to prosecute doctors, provided they comply with official guidelines, has allowed for widespread use of euthanasia for terminally ill patients whether they are conscious or not. In Australia legislation in the Northern Territory, which was much opposed by a number of church leaders, made possible the assisted suicide of three patients until it was overturned by the Federal Parliament. And in the United States a Supreme Court verdict is awaited to determine whether or not individual states can legalise various forms of euthanasia. Even if, as is currently expected, the Supreme Court rules against such legislation, local courts have so far failed to convict Dr Jack Kavorkian for his open involvement in assisted suicide. Even in Britain it is now clear that the 1994 House of Lord's Select Committee Report on Medical Ethics, which argued decisively against legalised euthanasia and on which the then Archbishop of York, John Habgood, served, has not ended the debate.

Until recently most church leaders and theologians were agreed that both assisted suicide and active euthanasia were wrong and should not be condoned or legalised.1 They often argued that there were ambiguous situations in which the terminally ill could be given pain relief that might or might not shorten their lives. There were also other situations in which competent patients who were terminally ill themselves might properly decide against any further life-sustaining treatment. However, it was often argued that neither of these situations should be termed 'euthanasia' as such. The latter involved active intervention on the part of medical staff intended specifically to end a patient's life. Such intervention might take the form of assisted suicide in which medical staff help a patient to end his or her life. Or it might take the more active form of medical staff themselves bringing to an end the life of a compliant or comatose patient. In either case medical staff would be doing more than agreeing not to treat or treating only with the specific intention of controlling pain. Euthanasia in this strict sense involves medical assistance to, or action on, a patient with an intention of ending a human life. It will be seen later that this strict definition still has problems - not least in the ever more complex medical area of withholding or withdrawing treatment from the permanently comatose. However, for the moment 'medical assistance or action which is intended to end a human life' does at least provide a working definition of euthanasia in its strictest sense.

Euthanasia defined in this sense has obvious continuities with medically induced abortion. In so far as a fetus constitutes human life in some sense, medically induced abortion involves assistance or action which is intended to end a life. Both euthanasia and abortion are contrary to the Hippocratic Oath in its original form. There is, of course, considerable and probably unresolvable debate about the status of life of the fetus. Some hold that from conception this is a full human being who must be accorded full human rights and/or respect. Others argue that at most it is potential human life over which the rights or even concerns of the mother should always be allowed to prevail. However, whichever moral perspective or variant on these perspectives is taken, induced abortion does entail action which is intended to end a life. And the nearer to term that this action takes place, the more people whatever their perspective are likely to see abortion as approximating to euthanasia. Thus the recent debate in the United States about what are sometimes termed partial-birth abortions has highlighted just how narrow is the distinction between such late-term abortion and infanticide. Indeed, some people, such as the secular philosopher Peter Singer,2 argue that if abortion is permitted then so should infanticide. A severely malformed baby might even be accorded fewer rights than a higher primate. And just as malformed babies might legitimately be killed, so might permanently comatose adults or the terminally ill who wished to die. Given current advances in the care of premature births, third trimester abortions have many of the features of euthanasia in its strictest sense.

Even though there has been long history of theological and pastoral differences within churches on the propriety of early abortions, there is a more consistent tradition of condemning most late abortions, infanticide and suicide as sinful. Certainly for Augustine all would have been seen as murder and as theologically unjustifiable forms of human killing. In The City of God he even condemned the notion of altruistic suicide. Medically assisted suicide of the terminally ill would surely have been even less likely to have met with his approval. So he argued:

"Some women killed themselves to avoid suffering anything [like rape] and surely any man of compassion would be ready to excuse the emotions which led them to do this. Some refused to kill themselves, because they did not want to escape another's criminal act by a misdeed of their own. And anyone who uses this as a charge against them will lay himself open to a charge of foolishness. For it is clear that if no one has a private right to kill even a guilty man (and no law allows this), then certainly anyone who kills himself is a murderer, and is the more guilty in killing himself the more innocent he is of the charge on which he has condemned himself to death. We rightly abominate the act of Judas, and the judgment of truth is that when he hanged himself he did not atone for the guilt of his detestable betrayal but rather increased it, since he despaired of God's mercy and in a fit of self-destructive remorse left himself no chance of a saving repentance. How much less right has anyone to indulge in self-slaughter when he can find in himself no fault to justify such a punishment! For when Judas killed himself, he killed a criminal, and yet he ended his life guilty not only of Christ's death, but also of his own; one crime led to another. Why then should a man, who has done no wrong, do wrong to himself? Why should he kill the innocent in putting himself to death, to prevent a guilty man from doing it? Why should he commit a sin against himself to deprive someone else of the chance?".3

For Augustine human killing was only justified if it was done under authority. The apparent suicide of Sampson, for example, when he pulled down the temple on himself and others was finally justified for Augustine by the belief that God had ordered him to do this. If Sampson had simply decided to do this for himself, it would never have been justifiable, however worthy his intentions. Rather, it was justifiable for Augustine because he believed that Sampson acted on the authority of God.

Interestingly, it is possible to argue on Augustine's grounds that if euthanasia were legalised by a particular state then it would be justifiable for doctors within that state to practice it. Strictly speaking they would be acting under the authority of the state and not on their own authority. Unlike Tertullian, who abhorred human killing in any form, Augustine was prepared to sanction capital punishment and state wars provided that they were properly authorised. Of course, viewed from a late 20th century perspective his notion of authority here appears dangerously unconditional. It provides few of the safe-guards against unjust laws, coercive states and theocratic claims that have marred so much Christian history. Yet it proved an important stepping stone in making later distinctions between just and unjust wars and between killing and murder.

Apart from the issue of early abortion, the Christian tradition condemning medical assistance or action which is intended to end a human life has until recently seldom been challenged by theologians. Earlier this century a few church leaders in Britain such as Dean Inge and W.R.Mathews did challenge it, and in the United States the theologian Joseph Fletcher also did. However they were exceptions. For most church leaders and theologians the tradition was in tact and voices challenging it either inside the churches or outside were unusual. It was widely argued that it was not a proper or appropriate role for medical staff to end human life which had been given and sanctified by God. The proper role for medical staff was to save life and not to destroy it.

Given this understanding, the legalisation of abortion in 1968 represented a radical shift of medical ethos. It has continued to cause controversy within churches and is a source of ongoing theological disagreement. Now it seems likely that euthanasia will create similar divisions. The Christian tradition condemning medical assistance or action which is intended to end a human life is likely to come under increasing challenge within churches and amongst theologians. If once this might have been depicted as a debate simply between Christians and secularists, it is fast becoming also a debate amongst and between Christians. There are at least three reasons for this: changing attitudes within society at large which increasingly affect churchgoers too; ambiguities arising from ever more complex medical technology; and finally ambiguities inherent within theology itself. However there is a fourth factor - ambiguities in legislation - which may pull in the opposite direction.

Changing Attitudes

One of the factors which prompted the legalisation of abortion in Britain was a change in public opinion. Doubtless this was, in turn, shaped by such factors as evidence about the prevalence of illegal and particularly septic abortions. Whatever the reasons for the change, by the mid-1980s there was widespread support for abortion, especially in those cases where the woman's health was endangered, where the woman had been raped, or where there was a defect in the embryo. What is more, regular churchgoers also tended to support abortion in such cases. Sharp differences between churchgoers and non-churchgoers emerged only in cases of abortion where the couple reported that they could not afford to have a baby or where the woman simply said that she did not wish to have child. And even then, there was a minority of regular churchgoers, even amongst Roman Catholics, who supported abortion on financial or choice grounds.

Data which I have analysed from British Social Attitudes4 surveys, 1983-1987 combined, give a very clear insight into these changing attitudes and the way they also affect regular churchgoers. Asked whether or not abortion should be allowed on the grounds of the woman's health being endangered, 92% of Anglican weekly churchgoers thought that it should, as did 65% of Roman Catholic weekly churchgoers. 88% of Anglican and 63% of Roman Catholic weekly churchgoers thought that abortion should be allowed on grounds of rape. Amongst Roman Catholic monthly churchgoers this rose to 81%. The Church of England's Board of Social Responsibility report. Abortion: an Ethical Discussion, in 1965 argued against defective embryos being allowed as a legal ground for abortion. This distinguished report argued that such a ground would further disadvantage the disabled and offered a less than Christian understanding of what it is to be a person. However in the BSA surveys two decades later 82% of Anglican weekly churchgoers now supported abortion in such cases. Roman Catholics weekly churchgoers at 43% were distinctly less supportive, but amongst their monthly churchgoers this rose to 76%.

This is not to argue that churchgoers simply mirror the views of secular society in this area. Very clear and statistically significant differences emerged on financial and pro-choice grounds for abortion. Whereas 55% of nominal Anglicans who never went to church supported abortion on purely financial grounds and 45% on pro-choice grounds, amongst weekly churchgoers this reduced to 30% and 25% respectively. Amongst Roman Catholic weekly churchgoers support reduced still further to 15% band 12% respectively. So on these two grounds - financial and pro-choice - churchgoers on average were different from non- churchgoers. Yet this was not an absolute difference. More than a fifth of weekly churchgoers across denominations and more than a third of monthly churchgoers supported abortion even on these two grounds. Conversely about a half of the non-churchgoers did not give positive support for such abortions.

A very similar pattern amongst churchgoers and between churchgoers and non-churchgoers now seems to be emerging on the issue of euthanasia. There is increasing evidence for popular support of euthanasia in certain circumstances, even amongst regular churchgoers. Again using data which I have analysed from British Social Attitudes surveys, this time 1983-1984 combined, the following pattern emerges. Most people, including many churchgoers, support changes in the law which would allow euthanasia or assisted suicide for the terminally ill. Conversely, few people support the legalisation of euthanasia simply for those who are tired of living but are not terminally ill. There are clear differences between churchgoers and non-churchgoers in this area, yet they are by no means absolute differences.

76% of the whole sample in 1983-4 were in favour of euthanasia being allowed for the terminally ill and in 1994 this rose to 82%. Support amongst monthly churchgoers across denominations at these two decades differed little from the sample as a whole - it was 72% and 84% respectively. It was only amongst weekly churchgoers that a statistically significant difference emerged, with support at 48% and 45% respectively. Amongst Anglican weekly churchgoers in 1983-4 support rose to 66%. Clearest opposition to this form of euthanasia was amongst Roman Catholic weekly churchgoers: here only 39% supported it, although amongst monthly attenders this rose to 75%. Amongst the 1983-4 weekly churchgoers across denominations, age was not a strong predictor of attitudes: 47% of those aged 18-39 and 51% of those aged 60+ expressed support for euthanasia being allowed for the terminally ill.

In 1994 BSA asked people whether they thought that the law should let close relatives assist the suicide of the terminally ill. 54% of the sample as a whole agreed that it should. Again only 25% of weekly churchgoers agreed, yet amongst monthly churchgoers this rose to 52%. Directional statistical analysis on this and the previous question does suggest that the more an individual goes to church the less likely she or he is to accept the legalisation of euthanasia or assisted suicide. Nonetheless, there is still a clear minority of weekly churchgoers who do accept such legislation and a clear minority of non-churchgoers who do not. Even the 1983-4 question about allowing for euthanasia for those who are simply tired of living showed that 6% of weekly churchgoers, as distinct from 12% of the sample as a whole, agreed to this.

It is still to early to analyse the very detailed questions asked about euthanasia in the 1995 BSA survey.5 For the first time this survey asked people to make judgements about eight different euthanasia scenarios, ranging from euthanasia for the permanently comatose to assisted suicide for those who are simply tired of living . Once again it suggests strong popular support for medically administered euthanasia for the terminally ill, together with a fairly nuanced understanding of differences between the scenarios. People do seem prepared to make distinctions and do not give undifferentiated support for euthanasia in any form. So there appears to be strong support for euthanasia/assisted suicide for those who are terminally ill, but little for those who are not but are simply tired of living. There is also strong support for withdrawing life support from the permanently comatose. In addition, churchgoing appears to be a highly significant variable in predicting attitudes towards euthanasia. Indeed, regular attendance at a place of worship seems to be a more significant variable than age, gender or social class. So, combining all the different scenarios, weekly churchgoers have a rating of 3.95 on an 8 point scale [i.e. just less than half support the different forms of euthanasia] whereas non-churchgoers have a rating of 5.08 and those saying they have no religion 5.53.

It is often argued that Christian ethics cannot be shaped by opinion polls. Yet, since this data gives evidence about the attitudes of regular churchgoers, it might seem less than prudent for Christian ethicists simply to ignore it. Churchgoing does appear to modify support for euthanasia. Those, like myself, who are cautious about supporting any legislation allowing euthanasia can draw some comfort from these statistics. Nevertheless, there is also clear evidence, especially amongst Anglican regular churchgoers, that a majority of the laity do seem to support change, at least for the terminally ill.

Changes in Medicine

The second factor which challenges traditional Christian condemnation of euthanasia is medicine itself. In the public's mind, modem medicine may have become too efficient at saving and prolonging life. The opinion poll data suggest strongly that there is widespread popular support amongst both churchgoers and non-churchgoers for medical assistance or action which is intended to end the life of a terminally ill patient. This is not indiscriminate support based upon an unqualified pro-choice perspective. There appears to be little public support for allowing euthanasia for the non-terminally ill who are simply tired of life. And there is some hesitation about allowing close relatives to take the lives of even the terminally ill. Yet there does seem to be a belief that medical staff should be allowed actively to end the lives of both the terminally ill who desire this for themselves and the permanently comatose whose relatives agree. This belief may well be based upon a fear that modern medicine has become too clever at preserving life.

Many people apparently fear that their lives will be inappropriately prolonged by the increasing sophistications of modem medicine. The widespread publicity given to the Tony Bland case may well have added to this fear. Newspapers gave considerable space in the early 1990s to the efforts of his parents to have his life support removed. The House of Lords Judgement of 3 Feb 1993 finally allowed for this to happen and, thus, for Tony Bland to die. The case served to highlight some of the complexities created by advances in medical care. Apparently patients lacking any cortical activity - and thus without any ability to be sentient or conscious, let alone relate to other people - might have their lives prolonged for years if not for decades. Newspaper photographs of Tony Bland still in a fetal position three-and-a-half years after the Hillsborough disaster illustrated this graphically. The House of Lords' Report on Medical Ethics pointed out that few of the public when questioned wished to be kept alive in such a state themselves. The 1995 BSA data confirm this.

It is sometimes argued that other advances in modem medicine, particularly in palliative care, work in the opposite direction. For example, the House of Lords' Report on Medical Ethics noted that palliative care is not well developed in the Netherlands and argued that the legalisation of euthanasia in Britain might erode its impact here. This is an important point, but I doubt if it fully answers the widespread fear of both churchgoers and non-churchgoers. The fear may not simply be about racing intractable pain (an obvious concern for the conscious terminally ill) but about facing prolonged insentience. Involved in this are more complex issues of dignity, identity and being an unnecessary burden upon others.

Changes in Theology

This cluster of complex issues - dignity, identity and burden - raises the issue of euthanasia in a new form for theology. It might in the past have been sufficient simply to argue that human life is God-given and should never be taken by human beings outside a context of a just-war or just-punishment. However the dilemmas created by modem medicine seem to make such a clear-cut position increasingly difficult to hold. Is withdrawing life-sustaining medical treatment or intensive nursing care from a patient whose cortex is destroyed tantamount to euthanasia or not? Is withholding life-prolonging treatment with the agreement of conscious but terminally ill patients tantamount to assisted suicide or not? Modem medicine makes such questions unavoidable. Fine, but apparently arbitrary, distinctions need to be made to answer these questions - distinctions which seem to provide a less than firm foundation for theology in this area.

The 1996 Washington Report is remarkable because it takes seriously the role of theology, the complexities of the present medical situation and the ambiguities of lawmaking in this area. The authors are agreed that if euthanasia/assisted suicide is to be allowed at all then it should be allowed only for exceptional cases of terminal illness. However they fail finally to agree about whether or not even this should be allowed. Instead, they note the following theological paradox:

Paradoxically, those Christians who accept and those who reject assisted suicide and euthanasia begin with similar convictions. Both have a sense of the sovereignty of God. Both want to protect human dignity and to preserve the freedom of individual persons to choose how to confront human finitude and death. They view life as a gift that is good, but not entirely at the disposal of humanity... They recognise that human life, especially in situations of death and dying, often confronts us with a conflict of goods in which physical life clashes with other purposes or goods of life. Moreover, they are aware that advances in medical technology may be used to preserve and extend life apart from other goods in human life. They agree that among the goals of medicine are to relieve suffering and restore health, not simply to extend physical life.

This provides the third plank for my argument, namely that the Christian tradition condemning medical assistance or action which is intended to end a human life is likely to come under increasing challenge within churches and amongst theologians. A single example might illustrate this point. It is often argued by theologians in this context that human life is a gift, a gift from a loving God made know to us in Jesus Christ. The analogy of the gift-relationship finds its foundation in God's gift of the Logos and continues in the Logos' gift of life to us. We, in turn, should respond to this gift with gratitude, thanksgiving and deep responsibility. In contrast, those who lack this faith may see human life, not as a gracious gift, but as a chance by-product of a world that has meaning only if we choose to give it meaning. In theory at least, this second position allows human beings to shape human life as they will. If people decide to opt for euthanasia then that is their choice: life can be shaped as they will. Conversely, for Christians life is God-given and is not simply to be shaped by humans as they will, but to be approached gratefully and responsibly.

Yet in the context of modern medicine the contrast between these two positions is not nearly so clear-cut. Christian doctors, committed to the belief that life is God-given, still face the same dilemmas about prolonging the lives of the terminally ill or permanently comatose. Gift relationships are by no means all gracious - some can be highly manipulative, especially the required gifts of submission. Gracious gifts should be treated with gratitude and responsibility, but they not bind the one to whom they are given - it is manipulative gifts that do that. Gracious gifts can be enjoyed for a while and then shared with, or even returned with gratitude to, the giver. Gracious gifts leave both giver and receiver free. Indeed when God-given life becomes nothing but a burden, it might seem appropriate to return that life prayerfully and humbly to the giver.

Changes in Law

Taken together, changing attitudes within society at large which increasingly affect churchgoers too, ambiguities arising from ever more complex medical technology, and finally ambiguities inherent within theology itself, seem to make traditional Christian teaching about euthanasia less convincing today. Does this mean that Christians should support a change in legislation about euthanasia/assisted suicide? Clearly quite a number of churchgoers already believe that it does. My own position is more cautious. If the 1968 Abortion Law is a reliable precedent, then I fear that we may create a situation in which the vulnerable are made more vulnerable. Compassion may be replaced by function.

Without claiming that the legalisation of abortion and euthanasia are identical, the politics of the two do have a certain affinity. On the issue of abortion (and on divorce) in the 1960's the Church of England's Board of Social Responsibility supported changes in law, but discovered later that the actual changes de facto were far more permissive than it had intended. On compassionate grounds in the 1960s there was widespread support in society at large and amongst churchgoers for a change in the law. The Bourne case just before the war had raised public consciousness in this area. By the early 1960s it was argued that there were strong compassionate reasons for changing the law - especially for women who had been raped, for those too young or with too severe learning disabilities to be aware of the consequences of sexual intercourse, or for those whose health was severely at risk. It was also argued, using a mixture of compassionate and pragmatic grounds, that induced abortion was a fact of life and could be done safely by public (or private but legal) health service or at considerable risk to the women involved by illegal abortionists. The 1968 Abortion Law was widely seen as compassionate response, allowing for abortion for the disadvantaged. Yet very quickly it was realised that a liberty for the few on compassionate grounds had become a right for women on any grounds. Soon abortion clinics argued that since early abortion was safer for the woman than having a baby, then abortion in the first trimester at least could always be justified in terms of the Abortion Law.

This I believe is still the central dilemma confronting attempts to legalise euthanasia in its strict sense. Given the way legal systems inevitably work, how can we prevent a liberty being turned effectively into a right? This is de facto what has happened in the Netherlands. The House of Lord's Report on Medical Ethics argued that strict grounds for euthanasia are simply not applied there. In addition, it has become increasingly difficult to get juries in the Netherlands to convict doctors who disregard official procedures. It seems that once a line is crossed on such issues, then any kind of control becomes ever more difficult.

My own fear is that by introducing legislation in this area on compassionate grounds we may create a society which is distinctly less compassionate. In such a society the elderly may feel pressured not to continue their lives at the expense of the young. The permanently disabled may feel the same. The health service may put less resources into palliative and geriatric care. In short, we will have become a less compassionate society - a society even more distant from the injunctions of Matthew 25.

In the absence of legislation we will, of course, still have problems. For example, there is continuing debate about what guidelines are appropriate for the permanently comatose - both in terms of the reliability of diagnoses and the degree of consciousness of those deemed to be in a 'permanent vegetative state'. There are continuing moral debates about the status of withholding and especially withdrawing treatment and/or intensive nursing care. Nevertheless, experience from the legislation on abortion should, I believe, make Christians cautious about the possibility of legislation on euthanasia.

So my own position remains cautious despite the growing pressure from public opinion allied to the dilemmas raised by modem medicine. 1 fear that we are still too confused to legislate safely in this area.

Notes
  1. See further, Robin Gill, Moral Leadership in a Postmodern Age, T and T Dark, Edinburgh, 1997, chapt.10
  2. Peter Singer, Rethinking Life and Death, OUP, Oxford, 1995.
  3. From The City of God, trans. Henry Bettenson and ed. David Knowles, Penguin edition, 1972,1.17.
  4. The data used here were made available through Data Archive. The data were originally collected by the ESRC Research Centre on Micro-social Change at the University of Essex. Neither the original collectors of the data nor the Archive bear any responsibility for the analyses or interpretations presented here.
  5. For a discussion, see Roger Jowell, John Curtice, Alison Park, Lindsay Brook and Katarina Thomson (eds), British Social Attitudes the 13th Report, Social and Community Planning Research, Dartmouth, Hants, 1996.


Guild of St Raphael