Introduction: What Is “Euthanasia”?
In order to speak of euthanasia from the perspective of Orthodox moral theology, it is important to begin by defining our terms. “Euthanasia,” like “Physician Assisted Suicide” (PAS), refers to an intentional act, usually on the part of a physician, that shortens the life of a patient by introducing some foreign, lethal substance into the patient’s body. With PAS, the physician provides medication that the conscious and presumably competent patient self-administers, whereas with euthanasia the medical team intervenes directly and actively to hasten the patient’s death.
This means that a clear distinction must be made between what have traditionally been labeled “active” and “passive” forms of euthanasia. The latter term, “passive euthanasia,” refers generally to a withdrawing or withholding of life-support, rather than to active intervention. As such, it is a misnomer. Modern life-support technology can sustain biological existence even when the patient has lost autonomous cardio-respiratory functioning or has suffered the irreversible loss of upper brain activity. Although the brain stem may still be working, if the cerebral cortex is dead, life-support technology (ventilator, dialysis, antibiotics) is doing little more than sustaining a living cadaver. In liturgical language, this state signals that “the soul is struggling to leave the body,” and there is no longer personal existence in any meaningful sense.1
Accordingly, we should do away with the expression “passive euthanasia,” since it refers to an omission that merely allows the dying process to run its course. The patient dies not from active intervention on the part of the medical team, but from the underlying pathology. As Roman Catholic statements have insisted since the early 1980s, withholding or withdrawing life-support, or otherwise refusing to apply certain medical therapies that do not serve the patient’s interests but merely prolong the dying process, do not constitute euthanasia.2 Considering the relationship between burdens and benefits, such passive actions in cases of terminal illness may be considered morally appropriate, even mandatory.
The expression “euthanasia,” of course, has lost its original meaning of “a good death.” In current usage, it refers to an unnatural invasion into the life of the patient, the sole purpose of which is to hasten death. When we use that unfortunate expression, we are speaking about active intervention that intends to shorten the patient’s life, usually in order to end severe suffering and to short-circuit the stress and distress of the dying process. With the legalization of euthanasia in England, Holland and Belgium, it has become evident that some acts of euthanasia also occur in cases where the patient is not dying. The procedure in such cases is intended to address psychological issues commonly associated with depression. Here the question is legitimately posed as to whether such an action constitutes suicide on the part of the patient or homicide on the part of the physician.
With this understanding of the term “euthanasia,” I would like to address certain key theological questions from an Orthodox Christian perspective. These include: 1) the meaning of “death” in Orthodox thinking; 2) the redemptive value of suffering; and 3) appropriate accompaniment of the dying person.
The Meaning of “Death”
It is a commonplace today to say that Western culture is marked by a deep-seated fear of death. In fact, the real source of fear among our contemporaries is not death so much as it is the dying process. The media, for example, is filled with images of persons in hospital intensive care units, maintained (often against their will) on burdensome life-support, as their life slowly, painfully and relentlessly ebbs away. In such cases, death itself is regarded as a release, a blessed escape from meaningless suffering. Just as common is a quasi-gnostic, dualistic image of death that welcomes it as the liberation of the soul from the body and an exodus from this earthly “vale of tears.” If death is dreaded today, it is because to most people’s minds it marks the end of their existence, the frustration of their ambitions, and proof that life is ultimately meaningless.
In the perspective of the Scriptures, however, death is an implacable enemy. Death has entered the world as a violent intrusion into the created order, a consequence of human sin and rebellion against God, who created man for life and immortality (Gen 2:17; Rom 5:12; 6:23; 1 Cor 15:56).3 Yet death is a two-edged sword. While man’s sin leads to death, the fear of death leaves man in a state of profound anxiety that provokes him to sin; his corrupted nature is marked by an inescapable propensity toward sin. Thus death is seen not only as the consequence of human sinfulness, but also as its cause.
It is in this perspective that the apostle Paul would speak of death as “the last enemy” (1 Cor 15:26). In the earliest strata of the Old Testament, death is a realm in which God is absent (“In Sheol there is no remembrance of Thee,” Ps 6:5; cf. Ps 29/30:9; 87/88:12;114/115:17; Isa 38:18). Gradually Israel came to recognize that God is indeed present in the realm of the dead, with the purpose of calling his people from darkness to light, from death to life. With the apocalyptic prophecy of Daniel (mid-2nd c. BC) we find the first explicit reference in Hebrew literature to resurrection and judgment, leading to life beyond earthly existence. Finally, St Paul would declare that through the redeeming work of God in Christ, death is transformed into a pathway to everlasting life in the Kingdom of God, where “what is mortal is swallowed up by life” (1Cor 15:54; 2 Cor 5:4). Through the transforming power of Christ’s death and resurrection, death is overcome; the “last enemy” is vanquished.
This leads to a further insight provided by the apostle, namely that our true death occurs not at our physical demise but at our baptism. In Romans 6, he asks rhetorically: “Do you not know that all of us who have been baptized into Christ Jesus were baptized into death?” And he continues: “We were buried therefore with him by baptism into death, so that as Christ was raised from the dead by the glory of the Father, we too might walk in newness of life.” This, however, means that death can also be seen as a “friend,” and not only as an enemy. This ambivalence toward death finds expression especially in monastic literature, where the monk speaks longingly of death – not as liberation from the sinful body, but as the blessed end of physical existence and the transformation of the physical body into the eternal, spiritual body.((A good contemporary example of this perspective is provided by the Romanian monk, Fr Savatie Bastovoi, in his lecture “Invitation to Death,” published on CD by Patmos publishing co., Cluj-Napoca, 2003.))
In a truly Christian perspective, then, death is a conquered enemy, whose “sting” has been eliminated by the life-giving death of Christ on the Cross (1 Cor 15:54-57). By his resurrection from the realm of death, Christ has vanquished the power of death, and thereby he has transformed our “living death” into a new life of love, joy and hope (Rom 8:31-38).
This biblical witness will not answer some of today’s most pressing questions concerning the “moment of death”: that is, the criteria to be used in order to determine just when the person is no longer physically present, when “the soul has departed the body.” Among Orthodox ethicists there continues to be disagreement as to whether the final criterion for determining death should be the irreversible cessation of cardio-respiratory function, or rather what we refer to as “brain death.” Then again, in the latter case, there is no full agreement as to the definition of “brain death.” By that term some mean “death of the whole brain, including the brain stem.” Others understand the expression to mean “death of the brain as a whole,” that is, death occurs when the brain no longer functions in an integrated fashion because of the irreversible deterioration of certain of its key elements. If the upper hemispheres (cortex, cerebrum and cerebellum) are “dead,” even if the brainstem continues to function, then according to this view the individual may be considered dead.
Then the question arises: is a person whose upper brain is dead, but whose brain stem is still functioning, a candidate for burial or the harvesting of organs? Those who define “brain death” as “death of the brain as a whole” would likely reply “Yes,” whereas those who understand brain death to include the brain stem would definitely oppose such procedures. The debate is ongoing, and it has enormous implications for all of us. The brainstem alone is incapable of sustaining personal existence, the life of a moral agent. This fact leads many to conclude that death occurs with the death of the upper hemispheres. Others, however, point out that an accurate determination of such “death” is far from guaranteed; and where there is breath (which is sustained by the brainstem), there is by definition “life” (cf. Gen 2:7).
Resolution of the problem may lie in our agreeing on the meaning of “person.” Certainly, the soul is not spatially located in the brain. Soul is the divinely bestowed life principle that animates the entire organism. But when the upper brain is destroyed, when there is no capacity for a conscious and purposeful relationship with oneself, with others or, as a physical being, with God (since prayer is no longer possible), then we may conclude (resorting once again to liturgical language) that the soul has either left the body or is struggling to do so. In such a case, it seems only reasonable to conclude that the person has died; and our appropriate response is to offer the departed one into the merciful hands of God. (This does not necessarily mean, however, that it is morally acceptable to harvest organs at this point – but that is another issue.)
What is certain in Orthodox tradition and experience is that God has conquered death through the death and life-giving resurrection of his Son. However we may ultimately define death in physiological terms, we need to hold fast to the perspective of Scripture and Church Tradition. That perspective affirms that death is ultimately a spiritual state, a state of sin and alienation from God. That state, which characterizes our present life to the degree that we are enslaved to sin, can endure beyond our physical death. On the other hand, it can be transformed into an eternal participation in the very life of God. That transformation, leading to what Orthodox tradition terms theôsis or “deification,” flows forth from the life-giving sacrifice of Christ, which is the source and foundation of what we speak of as “redemptive suffering.”
The Redemptive Value of Suffering
One of the most difficult pastoral issues we have to face with our faithful is how we explain to them the mystery of suffering. The term mystery in this context must be understood in its two quasi-contradictory senses. On the one hand, it signifies an enigma, a conundrum, an unfathomable paradox. Yet on the other, it is a true mysterion, a sacramental reality in human experience through which God conveys divine grace.
First, we need to be clear about the uniqueness of Christ’s own suffering and death, and about its meaning for us as members of his Body. A popular caricature has developed regarding Eastern and Western approaches to the work of redemption and the place of suffering in that work. Roman Catholic and Protestant theologies, it is held, locate the power and efficacy of Christ’s redemptive activity in his suffering on the cross (e.g., Anselm’s “satisfaction” theory, or Luther’s theologia crucis). Orthodoxy, on the other hand, is seen as stressing above all Christ’s resurrection from the dead. Opposition is thereby created between two theories of redemption, the one focusing on the Cross and death, the other on Resurrection and life.
All that needs to be said here in this regard is that Orthodoxy preserves a crucial equilibrium between death and life, suffering and victory. If Orthodox Christians demonstrate such profound and exuberant joy at the great feast of Holy Pascha, if they celebrate Christ’s rising from the dead as “the Feast of feasts,” it is only because Pascha is the culmination of a journey, assumed by the incarnate Son of God, that passed inevitably by the way of Golgotha. Without Holy Friday, there could be no celebration of resurrection, no lived experience of Christ’s victory over sin and death. As regards Orthodoxy (but as much could be said with regard to authentic Roman Catholic theology), the stereotype must be abandoned. The purpose of Christ’s redemptive work is to convey Life; but it can do so only by leading him along the way of the Cross. Life, therefore, is impossible without suffering: the suffering of our Lord, but also our own suffering.
In his letter to the Colossians, the apostle Paul makes what at first glance is a curious and troubling statement: “Now I rejoice in [my] sufferings [endured] for your sake,” he declares, “and I complete in my flesh what is lacking in Christ’s afflictions for the sake of His Body, which is the Church” (1:24). There is no question that to Paul’s mind Christ is the sole author of our salvation, that he and he alone accomplished all that was necessary for our redemption. How, then, can Paul speak of what is “lacking in Christ’s afflictions”? Very simply, he is speaking of the need for us to participate, to share in those afflictions as members of Christ’s Body, the Church. All is accomplished by Christ; yet our communion with him in his affliction “completes” or complements that suffering, insofar as we suffer as members of the universal Body of which he is the Head.
This means that our personal suffering can be infused with transcendent meaning. In the best of cases, it can be transformed from an experience of meaningless agony into a liberating and joy-filled communion in Christ. On the one hand, we share in his suffering; we “complete” his afflictions, by offering our own suffering to him, that he might infuse it with ultimate purpose. In some way we will never in this life fully understand, Christ uses our pain and anguish, particularly in the face of death, to complete and fulfill his work for the world’s salvation. Our suffering is never pointless, unless we will it to be so, unless we refuse to relinquish it into God’s hands to serve his purpose. There where we make of our suffering a true “sacrifice of praise,” as the apostle Paul declares, we share Christ’s own sufferings, becoming like him in his death, in order to attain, with him and in him, the resurrection from the dead (Phil 3:10-11).
Yet it is equally important to insist that Christ shares fully in our suffering as well. When the myrrh-bearing women appeared at the tomb, the angel declared: “You seek Jesus of Nazareth, the Crucified One (ho estavromenos); he is not here, he is risen!” Jesus, the resurrected and glorified Lord, remains forever “the crucified one,” who, in the apt words of Pascal, “is in agony until the end of the age.”
Redemption, therefore, involves suffering in two essential and complementary ways: Christ’s prior suffering that leads to death’s destruction, and our own suffering, which can so fully participate in his that we can declare, again with the apostle Paul, that “it is no longer I who live, but Christ who lives in me” (Gal 2:20).
This implies that we need to educate ourselves and our faithful about the true meaning of suffering, in order to provide a genuinely Christian vision of our condition and our hope in the face of death. Today the specter of death provokes untold anguish in the minds and hearts of so many people, because they have no such vision that makes sense of their suffering and still less of their impending death. Consequently, death remains an unconquered enemy, and its accompanying suffering remains a meaningless trial to be attenuated or eliminated as much as possible.
Yet the spiritual and ascetic tradition of Orthodoxy has always recognized the benefits that can come from suffering which is assumed in the light of Christ’s death and resurrection, assumed with humility and courage as a means of purification, a means of focusing on “the one thing needful” (Lk 10:42). Of course, physical and mental anguish can reach the point where the patient can no longer benefit from the pain he or she experiences; that pain can become an intolerable and dehumanizing burden. Then any talk of the “redemptive value of suffering” becomes specious, a mockery of the reality that seizes and overwhelms the dying person. Then euthanasia can seem like the only reasonable solution, the only acceptable “way out.”
What are the alternatives to euthanasia? To what degree can terminally ill patients assume their suffering in a way that is truly redemptive, that leads them to a deep and lasting communion with Christ rather than to despair? How, in other words, can we accompany the dying patient so as to provide appropriate physical, psychological and spiritual care?
Accompanying the Dying Patient
A current adage in the medical community holds that “we may not always be able to cure, but we can always care.” With this principle in mind, I would like to conclude with a few simple observations concerning the spiritual accompaniment we as members of the Body of Christ are called to offer to dying patients.
The most effective way to address the fear of dying persons in the face of impending death is to offer appropriate palliative care. We have come full circle in the debate over “medical heroics” in end-of-life care. Largely because of the threat of lawsuits, medical teams have often felt compelled to “do everything possible” to sustain a patient’s biological existence, to use any and every option medical technology offers, in order to ward off death. Now we realize that such “heroics” are in fact invasive and often violent violations – not only of patients’ “rights,” but more importantly of their personal integrity. Faced with the threat of legal action, we may be inclined to guarantee as far as possible patient autonomy. From the perspective of Christian faith, however, our primary concern should be to honor the inherent sanctity of personal human existence, to respect each patient as a bearer of the divine Image and called to eternal life in intimate communion with the glorified Christ. In this light, death becomes a passageway, a Paschal transformation, from earthly life to life beyond, life lived in the joy and blessedness of the communion of saints. And medical heroics are recognized for what they in fact are: either a safeguard against a charge of medical neglect and malfeasance, or an expression of unbridled hubris that regards the death of a patient as a personal failure on the part of the physician.
Palliative care, which avoids the pitfall of such hubris and strives to accompany the terminally ill patient with compassion, provides the best possible alternative to euthanasia. It is now widely recognized that the vast majority of requests for euthanasia, including physician-assisted suicide, come from patients who fear the dying process, who dread the prospect of intractable pain or of losing their dignity, their sense of self-worth, as they become increasingly dependent on others for their most basic bodily needs.
As it has developed in Western Europe over the past several years, the palliative care movement has concentrated in very effective ways on the problem of pain management. It is essential that the medical community, there as well as in the United States, continue its research and development in this area, to provide appropriate treatment of physical pain and to respond effectively to cases of depression. Terminal or palliative sedation constitutes an important aspect of such treatment. In the United States today there is concern among many medical specialists that sedation can mean euthanasia in disguise, that all too easily the sedated patient can be eased into a coma and left to die. It seems, nevertheless, that this is a groundless fear, provided the medical team is acting with professional integrity and responsibility. As a rule of thumb, we can say that the objective of end-of-life therapy is to maintain a maximum of consciousness with a minimum of pain. Where unbearable pain and suffering cannot be relieved, however, sedating medications in tightly controlled dosages might offer the best solution, guaranteeing for the patient an end to earthly existence that is truly “painless, blameless and peaceful.”
We may not always be able to cure, but we can and must always care. Such care is given by the medical team, but it is required as well of others within the Church, the Body of Christ. Death and the dying process should be recognized and honored as acts that are essentially ecclesial. The death of one member makes its impact upon the entire Body of believers, just as the sin of one member infects us all. How, then, can the Church – you and I – respond appropriately to the reality of death, especially as it tempts a dying patient or their loved ones to request euthanasia?
The answer, it seems, lies precisely in the notion of “accompaniment.” I may not be able to contribute to the patient’s physical care, but I can assure a presence: a presence of affection, compassion and love. In cases where the patient is comatose, it is important to remember that the last faculty to disappear is usually that of hearing. As priests, we often find ourselves at the bedside of terminally ill, comatose patients. What we do, however, any member of the Church can do: take the person’s hand, read psalms, speak quietly of God’s infinite love and compassion, and above all, pray. Pray aloud or in silence. But through that prayer, make an offering of the person to the Lord of life: “Thine own of thine own, we offer unto Thee….”
An often forgotten element of any pastoral ministry, however, is the care and accompaniment that need to be offered to grieving family members and friends. Grief is a process, often long and burdensome. It can be a crushing weight that results in depression and finally despair. When children are exposed to death and experience the loss of a parent or other person close to them, they often feel as though they themselves are responsible for that death. They need special attention, both from other family members and from those of us who can minister to them. We accompany the dying, to help them through the times when euthanasia or suicide seems attractive. We must do the same for those who grieve, since with the death of a loved one, a part of them dies as well.
The icon of the Dormition, the Falling Asleep of the Mother of God, provides for us the final word about death and hope beyond – a hope that can eliminate every temptation to a preemptive death by euthanasia. As much as the Paschal icon itself, the sacred image of the Dormition expresses the ultimate truth about death. On the iconastasis of every Orthodox church there is an image of Mary the Theotokos (“Bearer of God”), embracing the Christ-child, and at the same time offering him to the world as the source of the world’s life and salvation. Here, in the festal icon of the Dormition, we find the mirror image of that theme. Christ is seen standing behind the bier of the Virgin, holding in his arms the image of her soul. She has died, as every human being dies. She bore within herself the agony of her Son’s death, then she embarked on the pathway that led from her own grief-stricken life through the crisis of death. That crisis, however, was transfigured into the same victory achieved by Christ through his own death. The image of her soul that he embraces in the Dormition icon is therefore wrapped in a shroud of white, symbolizing resurrection. Like her Son, and because of his life-giving death and resurrection, she passes from death to life, from earth to heaven, to dwell with him in eternal glory.
For those whose response to the vicissitudes and afflictions of life is to succumb to the subtle and insidious temptation to seek euthanasia or to commit suicide, the Dormition icon represents the only viable answer, the only sure hope. “In falling asleep, you did not forsake the world, O Theotokos!”, we sing in the Troparion or festal hymn. Translated to life by her Son, the Author of life (Acts 3:15), she dwells in eternal communion with God, where she offers perpetual intercession for us and for our salvation. This assurance, that Mary is the first-fruits of Christ’s life-giving death and resurrection, and that she prays ceaselessly that we might share with her the gift of eternal life and joy, is the source and ground of our most fervent hope. The promise of the Dormition icon is that what Christ has done for his Holy Mother he will do as well for us.
This is the only final response we can offer to those who are tempted to resort to euthanasia or suicide as a way to escape the fear of a painful and protracted dying process. The answer to euthanasia is hope: hope in the victory of Christ over death, hope that in and through the “mystery” of our own death we will share fully in all the power and the glory of his resurrection.
- To quote an eminent American Orthodox ethicist, H. Tristram Engelhardt: “a body with whole-brain death, or with death of the whole brain except for the brain stem, does not support a mental life, much less the life of a person.” The Foundations of Bioethics (2nd ed., New York: Oxford University Press, 1996), 242f. [↩]
- See, for example, the statement, published by the Vatican Press in 1981, “Questions of Ethics Regarding the Fatally Ill and the Dying,” in Medical Ethics: Sources of Catholic Teaching, 116. On the other hand, the Catholic “Declaration on euthanasia,” issued by the Congregation for the Doctrine of the Faith (the Roman Magisterium) on May 5, 1980, defines euthanasia as “an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated.” It continues, however, with an important clarification: “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….” [↩]
- According to the Wisdom of Solomon (2:23f), “God created man for incorruption, and made him in the image of his own eternity (or nature), but through the devil’s envy death entered the world.” Here, as in Genesis, however, the devil’s role is that of Tempter; it is man who sins and thus alienates himself from his Creator. Man alone is responsible for his sin, and consequently for the death that is its inevitable consequence. [↩]