I Am My Brother’s Keeper: Communitarian Obligations to the Dying Person

I Am My Brother’s Keeper: Communitarian Obligations to the Dying Person Abstract Contemporary arguments concerning the permissibility of physician-assisted suicide [PAS], or suicide in general, often rehearse classical arguments over whether individual persons have a fundamental right based on autonomy to determine their own death, or whether the community has a legitimate interest in individual members’ welfare that would prohibit suicide. I explicate historical arguments pertaining to PAS aligned with these poles. I contend that an ethical indictment of PAS entails moral duties on the part of one’s community to provide effective means of ameliorating physical and existential suffering. I further elucidate how such duties have been affirmed by the Roman Catholic Church. My aim is to provide reasons why the expanding legalization of PAS should not preclude social investment in effective palliative care and the provision of a communal presence to the dying as they confront their subjectively experienced suffering. I. INTRODUCTION The past two decades have seen myriad books and articles written by ethicists, moral theologians, lawyers, and sundry other academic scholars and professionals concerning the practice of physician-assisted suicide [PAS] or physician-aid-in-dying [PAD].1 This explosion of scholarship was sparked in the United States by the enactment of Oregon’s Death with Dignity Act in 1997 (Oregon Public Health Division, 2015). Since then, to date, five other US states—Washington, Montana, Vermont, Colorado, and California—and the District of Columbia have legalized PAS in some form or fashion. Furthermore, Canada has recently granted federal approval of PAS (House of Commons of Canada, 2016), and popular debate gained traction with the well-publicized death of Brittany Maynard via PAS (Maynard, 2014). Yet, arguments concerning the ethical or legal permissibility of PAS, or suicide in general, are nothing new; they trace back over 2,500 years in Western philosophical and religious traditions. In fact, today’s popular and scholarly debates often rehearse classical arguments over whether individual persons have a fundamental right based on autonomy to determine their own death, or whether the community in which individuals are unavoidably embedded has a legitimate interest in their welfare that would prohibit suicide—with or without the assistance of medical professionals.2 I will explicate some of the historical arguments that pertain to the contemporary debate over PAS aligned with the poles of individual autonomy versus communal interest. I contend that an ethical indictment of PAS does not merely negate a terminally ill person’s putative freedom to end his life,3 but entails moral duties on the part of his surrounding community—defined in various levels as discussed below—to provide effective means of ameliorating his physical and existential suffering. I will elucidate how such duties have been affirmed by one of the foremost voices opposing PAS: the Roman Catholic Church. I will not specifically argue here against the legalization of PAS, though the claims affirmed herein could be utilized to construct such an argument and Christians have well-argued reasons to stand in opposition to PAS (Grisez and Boyle, 1979). Rather, my aim is to provide reasons why the expanding legalization of PAS should not preclude social investment in effective palliative care and overall caregiving, providing a communal presence to the dying as they confront their subjectively experienced suffering.4 II. LIBERTARIAN AND COMMUNITARIAN ARGUMENTS REGARDING PAS5 A prominent argument in favor of the moral and legal permissibility of PAS is based on a fundamental ethical imperative to respect the informed, reasoned choices of substantially autonomous individuals.6 In overturning a legal prohibition on PAS in the state of Washington, US District Judge Barbara Rothstein contends, “There is no more profoundly personal decision, nor one which is closer to the heart of personal liberty, than the choice which a terminally ill person makes to end his or her suffering and hasten an inevitable death” (Compassion in Dying, 1996). John Harris goes so far as to condemn laws prohibiting PAS7 as “tyrannous” insofar as such laws “deny a person control of what, on any analysis, must be one of the most important decisions of life . . . which like all acts of tyranny is an ultimate denial of respect for persons” (Harris, 1995, 19–20). This categorization implicitly invokes John Stuart Mill’s declaration of the inherent “sovereignty” mature persons have over their own minds and bodies, which merits a fundamental respect in the absence of a compelling communal interest in preventing harm to others (Mill, 1869, I 9). Mill nevertheless supports legal prohibitions on acts that would, even if voluntarily entered into, nullify one’s liberty—such as selling oneself into slavery or risking one’s life in a duel. Regarding the former, Mill (1869, V 11) states, The reason for not interfering, unless for the sake of others, with a person’s voluntary acts, is consideration for his liberty . . . But by selling himself for a slave, he abdicates his liberty; he foregoes any future use of it beyond that single act . . . The principle of freedom cannot require that he should be free not to be free. It is not freedom, to be allowed to alienate his freedom. Mill’s valuation of liberty entails equal valuation of the necessary conditions for one’s exercise of liberty, the foundation of which is one’s life. As Christopher Kaczor contends, “Since all liberty rights arise from the right to life, one simply cannot have a liberty right to end one’s life, for this would be to undermine the original source of the liberty right” (Kaczor, 1998, 198).8 In contrast to Mill’s libertarian account, Immanuel Kant (1997) conceptualizes autonomy not as the exercise of an individual’s will without internal or external constraints, but rather as the will’s capacity to self-legislate—that is, to govern oneself in accordance with the rationally understood moral law. The exercise of self-legislation, however, includes “an implicit communal dimension that recognizes a shared interest or law . . . that treats all people as ends [in themselves] . . . Kant’s autonomy implicitly involves a relational component” (Ridenour and Cahill, 2015, 114). This Kantian understanding of the role of autonomy aligns with the more classical views of Aristotle and Thomas Aquinas, both of whom consider individuals to be inextricably members of a community. As such, certain natural limits are imposed on an individual’s exercise of his moral agency in light of demands of the common good. The common good is not merely the aggregate of satisfied preferences across a majority of individuals. Rather, this concept signifies mutual individual and collective flourishing: Individuals only flourish within a community, and the flourishing of a community should redound to that of each individual member thereof.9 In relation to the case at hand, Aquinas draws on Aristotle in one of his three indictments against suicide: “every part as such, is of the whole. Now every man is part of the community: and so as such, is of the community. Hence in the case that he kills himself, he causes injury to the community” (Summa Theologiae [ST], II-II, q. 64, a. 5).10 All human persons are interrelated in variously defined political communities. We can also be said to belong to one overall human community, which transcends nation, race, and gender boundaries. As a result of this conception of human nature, one that is essentially communitarian, Aquinas holds that each individual human person is responsible not only to himself, but also to every other member of the human community.11 Thus, suicide is not a purely private action with implications only for the suicidal agent. There are, of course, multiple levels of human communities, so it is important to ask to which level of community one owes a duty not to commit suicide, and thus conversely which level of community owes its members supportive care to ameliorate their suffering such that suicide becomes less of a considered option. For Aquinas (2007, I 2), following Aristotle, it was the polis—that is, the state—which is charged with crafting legislation aimed at helping its constituent citizens to flourish as living, sentient, social, and rational animals. Scully notes that the function of the state is to design laws that serve the well-being of the body politic “by promoting an environment in which local communities, families and individuals may subsist and develop as human, rational, moral beings” (Scully, 1981, 428). The polis comprises multiple forms of smaller social communities—for example, households, clans, and villages—as well as ecclesiastical communities—for example, parishes, dioceses, and religious orders—and other forms of association—for example, confraternities and guilds. It is noteworthy that, although Aquinas follows Aristotle in defining human beings as essentially “political animals,” he also distinctively refers to human beings in certain contexts as “social animals” (see ST, I, q. 96, a. 4; ST, I-II, q. 61, a. 5; ST, I-II, q. 95, a. 4; ST, II-II, q. 114, a. 2 ad 1; ST, III, q. 65, a. 1).12 In line with the principle of Catholic Social Teaching known as subsidiarity (Pontifical Council for Justice and Peace, 2004, pt. I, ch. 4, §iv), whereas an individual’s negative obligation not to commit suicide is with respect to the larger political community, there is a corresponding positive obligation on the part of one’s more closely-delineated social community (or communities) to assist one in meeting one’s negative obligation: “Since a human being is a social animal, one human being naturally owes to another whatever without which the conservation of human society would not be possible” (ST, II-II, q. 109, a. 3 ad 1; Aroney, 2007). If, as Aquinas argues, the conservation of human society requires individual members not to commit suicide, then such individuals are owed by others within society whatever assistance they need not to consider such a drastic option. Those who are closest in relationship to such an individual are, pragmatically speaking, typically in the optimal position to provide such assistance. Hence, this positive obligation falls, in addition to one’s professional caregivers, primarily on the shoulders of one’s social networks of family, friends, church community, neighbors, etc., with the circle of responsibility growing wider as more immediate caregivers require additional support to provide the needed assistance—for example, paid time off of work provided by employers, social security and disability benefits, and other forms of political assistance. David Hume (1783) counters each of Aquinas’ indictments of suicide, contending—also in anticipation of one of Kant’s (1997) arguments against suicide—that there is no rational basis for construing suicide as a violation of a moral duty to oneself.13 He further argues that it is unreasonable to view suicide as detrimental to the common good: A man who retires from life does no harm to society: He only ceases to do good; which, if it is an injury, is of the lowest kind. All our obligations to do good to society seem to imply something reciprocal. I receive the benefits of society, and therefore ought to promote its interests; but when I withdraw myself altogether from society, can I be bound any longer? But allowing that our obligations to do good were perpetual, they have certainly some bounds; I am not obliged to do a small good to society at the expence of a great harm to myself; why then should I prolong a miserable existence, because of some frivolous advantage which the public may perhaps receive from me? (Hume, 1783) In contrast to Hume’s conceptualization, David Novak (1975, 66) stresses Aquinas’ view of the reciprocal responsibility between an individual and the community in which he lives: “the person owes the community loyalty and service in return for the just distribution of society’s goods he has received.” The set of “goods” a community owes to its members is what counts toward the fulfillment of their nature—that is, what satisfies their natural desires. Such goods include not only the fundamental good of life, but also various other goods that need to be cultivated within a person in order that he may live to the fullest extent of his nature. Novak (1975, 66) cites certain virtues as examples: “In a true communion of persons one can see a need for even the helpless and infirm. Their very presence enables us to practice the human virtues of benevolence and generosity.” Even a “helpless and infirm” member of a community can remain a contributing member by assisting others in the cultivation of fulfilling goods, while at the same time preserving the fundamental good of his own existence. Every community owes its members this capacity to be of such service to others and to be served by others in return. Hence, it would violate a community’s basic duty to its citizens if it permitted some to view themselves as useless, non-contributing members, for such would not be the truth of the matter. PAS, even more so than unassisted suicide, points to the inescapably relational dimension of the act undertaken: “Euthanasia and PAS are not private matters of self-determination. They are acts that require two people to make either act possible and a complicit society to make either act acceptable” (Callahan, 1997, 76). Callahan (2000, 115–6) thus contends that, not only does respect for the individual right of self-determination not entail allowing for PAS, but also the practice of PAS obviates communal obligations to suffering members: By assuming that the relief of suffering is a goal important enough to legitimate killing as a way of achieving it, we corrupt the idea of such relief as a social good and duty. We cease helping to bear one another’s suffering, but eliminate altogether the person who suffers. We thereby jeopardize both the future of self-determination and the kind of community that furthers its members’ capacity to bear one another’s suffering. Why bear what can be eliminated altogether? For the sake of controlling the conditions of death, we would introduce a fundamental change in the conditions of living a life. In the name of controlling our mortality, we would enter a claim to change the nature of human relationships. If PAS violates the reciprocal responsibilities between individuals and their communities in service of the common good, what alternative courses of action would fulfill these responsibilities, and what specific goods should they promote? III. ADDRESSING THE NEEDS OF THE DYING14 In addition to a liberal, individualistic conception of autonomy and a putative ethical mandate to acquiesce to the informed, reasoned choices of terminally ill persons, probably the most influential argument in favor of PAS is that it is a function of the medical profession’s fundamental duty of beneficence to alleviate suffering. Of course, pain may often—though not always barring complete sedation—be treated effectively by analgesic medication. Suffering, however, comprises more than pain to include other physical, existential, social, and psychological burdens, such as the loss of independence, sense of self, and functional capacities that some persons feel jeopardize their dignity. PAS is argued to be a compassionate response to such unremitting physical and existential suffering. In fact, pain and other physical symptoms are not among the primary reasons cited for requesting PAS. In Oregon, the three most frequently mentioned end-of-life concerns are loss of autonomy (91.4%), decreasing ability to participate in activities that made life enjoyable (86.7%), and loss of dignity (71.4%) (Oregon Public Health Division, 2015, 5).15 As an alternative to PAS, I contend that the presence of loving caregivers can assist terminally ill patients with respect to these more commonly cited dimensions of their overall experience of existential suffering. Although not all patients will find meaning or value in their suffering as they approach the end of life, the question must be explored whether PAS is being promoted as an option prior to having exhausted all other communal caregiving opportunities to help patients potentially derive meaning or value from their remaining natural lifetime. Although suffering has no intrinsic value, there are a number of religious and secular reasons why suffering patients may potentially find their suffering to have an instrumental value. The opportunity to explore this potential is occluded by a premature offering of PAS as the only or most choiceworthy means of optimizing a “good death” or a “death with dignity.” Although the former term is the literal translation of the Greek root of “euthanasia”—eu-thanatos—and the latter term is the hallmark catch-phrase of PAS proponents (Humphry, 1992), the concept of a dignified death does not entail moral advocacy for PAS depending on how one defines the ambiguous concept of “dignity” in relation to human persons. I will describe various ways in which terminally ill patients may exemplify their dignity, understood in a Thomistic Aristotelian sense, as they confront physical and existential suffering (Gentzler, 2003). Among various religious traditions is the view that suffering may be redemptive in the sense of serving to attain some larger social or higher spiritual good. For example, within the Christian tradition, Pope John Paul II (1984, n. 19) contends, In the Cross of Christ not only is the Redemption accomplished through suffering, but also human suffering itself has beenredeemed . . . Every man has his own share in the Redemption. Each one is also called to share in that suffering through which the Redemption was accomplished . . . each man, in his suffering, can also become a sharer in the redemptive suffering of Christ. Suffering may also be understood as a source of repentance and atonement for past moral wrongdoing, both as a precursor to the temporal suffering one may endure in purgatory, with its spiritually purifying effect, and as a source of spiritual healing prior to death: “Suffering must be for conversion, that is, for the rebuilding of goodness in the [sufferer], who can recognize the divine mercy in this call to repentance” (John Paul II, 1984, n. 12; Fernandes, 2001). Less punitively, suffering could constitute a trial by means of which the patient is able to cultivate or exercise certain laudable traits of moral character: Suffering as it were contains a special call to the virtue which man must exercise on his own part. And this is the virtue of perseverance in bearing whatever disturbs and causes harm. In doing this, the individual unleashes hope, which maintains in him the conviction that suffering will not get the better of him, that it will not deprive him of his dignity as a human being, a dignity linked to awareness of the meaning of life. (John Paul II, 1984, n. 23) William Stempsey invokes the example of a marathon runner at the 1996 Olympic Games who injured himself but continued limping to the finish line, finally reaching it ninety minutes after the previous finisher to the applause of a crowd who faithfully remained to witness this display of courage and perseverance: “The admiration we feel for those who persevere in the face of great pain should tell us something about the moral goodness of those who reject suicide in the face of great suffering” (Stempsey, 1998, 214). This does not entail that those who fail to display such heroic virtues should be morally condemned. Rather, the point is that there is significant potential value that one may derive from their experience of suffering, an opportunity which PAS inherently denies. The exercise of virtues such as perseverance and hope may not only empower the suffering patient, but may serve as a powerful witness to caregivers16: When this body is gravely ill, totally incapacitated, and the person is almost incapable of living and acting, all the more do interior maturity and spiritual greatness become evident, constituting a touching lesson to those who are healthy and normal. (John Paul II, 1984, n. 26) To be clear, it is not being recommended that patients be forced to suffer merely as a means for the sake of providing a moral lesson for their caregivers. However, when suffering must unavoidably be endured—short of ending one’s life—then the possibility of the suffering patient serving as such a witness could help him to discover meaning and value in his continued existence, instead of experiencing himself as powerless, alone, and a burden on his caregivers. There are also several non-religiously based perspectives on physical and existential suffering’s potential instrumental value. First, echoing one of John Paul II’s claims above, how patients respond to their own suffering could constitute a source for developing and actualizing one’s moral character: “In our response to the mystery of suffering, we define ourselves, find our integrity and ultimately shape our ethos” (Fleischer, 1999, 485). Callahan (2000, 149) contends that how a terminally ill patient “masters” his dying exemplifies how he has lived his life: “How we die will be an expression of how we have wanted to live, and the meaning we find in our dying is likely to be at one with the meaning we have found in our living.” Far from suffering entailing passive weakness, confronting it could be means of transcendence in the Nietzschean sense of “overcoming” oneself into a “higher order” of humanity through effort and striving—not avoiding distress, but rather knowing it as an essential condition of one’s animal condition (Nietzsche, 2001, I 48 passim).17 How one responds to suffering is also an exercise of autonomy: “When I have options to my suffering, suffering is greatly reduced. A sense of impotence, a lack of control over my own destiny, aggravates suffering or, sometimes, can convert pain to suffering” (Loewy, 1991, 11). Of course, having PAS as a legal option expands one’s range of what may be autonomously chosen. Yet, in one statewide survey in Oregon, approximately a third of individuals who had PAS as a legal option instead autonomously elected to persist to the natural end of their lives; interviews suggested that possessing the lethal prescription may have provided them with “a sufficient sense of control” (Bascom and Tolle, 2004, 87). Although it may seem irrational on the surface for someone who possesses autonomously chosen means to end their suffering to elect not to do so, Stanley Hauerwas (1986, 33–4) counters that suffering is actually an essential ingredient for the exercise of autonomy: [W]e only gain autonomy by our willingness to make suffering our own through its incorporation into our moral projects. For autonomy is a correlative of our having a narrative through which we can make our suffering our own. Insofar as medicine denies us our suffering, rather than being a way to regain autonomy, it can be a threat or temptation to lose our autonomy. In addition to promoting individual autonomy, Marsha Fowler (1996, 49) argues that the shared experience of suffering among patients and their caregivers may become a source of solidarity: We do define ourselves in suffering both as individuals and as participants in the shared human condition . . . It is in suffering that we sense profoundly that our afflictedness at once is both intensely private and isolative, and yet held in common with all humanity. Our creatureliness, our lack of control, our consanguinity, our individuality and our co-humanity confront us in suffering . . . Suffering is not ours to control in the sense of its random intrusion into our lives. It is ours to control in terms of how we respond to it individually and collectively. Creating bonds of solidarity is essential to proper caregiving since the inherent nature of suffering unavoidably results in a degree of separation from the community of healthy persons surrounding oneself: Suffering, in a sense, separates persons from community. Suffering persons tend to withdraw into themselves and to feel alienated from a community going on with its daily lives and tasks while they suffer. When communities ignore those within their embrace who are suffering and when they treat them uncaringly or callously the integrity and solidarity of community is shattered. (Loewy, 1991, 13) Finally, although the promotion of meaning and value for the suffering patient should be the community’s paramount concern, a valuable by-product of the provision of proper communal attention is the effect it may have on the cultivation and exercise of virtue among caregivers. Emmanuel Levinas (1988), invoking the ethic of alterity popularized by Martin Buber (1970), exhorts that suffering teaches us to care for others and endows whatever suffering we may experience in providing such care with meaning. It is crucial to emphasize that caring for suffering others does not entail merely empathy or sympathy, but requires being present with them: The compassionate person is not removed from the suffering of the other – there is no distance between them . . . The person who is compassionate before and with the sufferer enters into their suffering, shares in it, and helps to bear the cross endured . . . He is available, present, consoling, and suffers in solidarity with the sufferer. In his compassionate presence as a co-sufferer love deepens the relationship and illuminates the meaning and purpose of suffering. (Nichols, 2013, 382–3; cf. Fowler, 1996, 52) It must be acknowledged that this call to “co-suffer” in solidarity with patients places great stress on caregivers, professional and otherwise, particularly if the patient’s illness persists for months or even years.18 Thus, the supportive net of caregiving must extend outward to encompass others who offer care for a patient’s immediate caregivers, whether through communal volunteer efforts—for example, respite care provided by volunteers from one’s church home—or governmental support mechanisms—for example, protected time off of work under the US Family Medical Leave Act; not to mention more appropriate work-hours, compensation, and mental health support for health care professionals who experience disproportionately high rates of burnout compared to those in other professions (Shanafelt et al., 2015). In the following sections, I will illuminate how the Roman Catholic Church and other scholars advocating a broadly communitarian ethic have reinforced this call to provide effective and authentically compassionate responses to suffering as an alternative to PAS. IV. CATHOLIC MORAL PERSPECTIVE CONCERNING PAS The Roman Catholic Church’s moral condemnation of PAS is based in large part on Aquinas’ arguments against suicide, particularly his third indictment, which is premised on a theological understanding that all human persons are ultimately subject to God (ST II-II, q. 64, a. 5). In its most definitive statement regarding PAS, the Vatican’s Congregation for the Doctrine of the Faith concludes: Human life is the basis of all goods, and is the necessary source and condition of every human activity and of all society. Most people regard life as something sacred and hold that no one may dispose of it at will, but believers see in life something greater, namely, a gift of God’s love, which they are called upon to preserve and make fruitful . . . Intentionally causing one’s own death, or suicide, is therefore 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 also often a refusal of love for self, the denial of a natural instinct to live, a flight from the duties of justice and charity owed to one’s neighbor, to various communities or to the whole of society – although, as is generally recognized, at times there are psychological factors present that can diminish responsibility or even completely remove it. (Congregation for the Doctrine of the Faith, 1980) This argument is based not so much on God’s “ownership” of human lives, but on the consequent call to proper “stewardship” of one’s embodied life, which has an inherently relational, communitarian dimension (Schotsmans, 2003b). Solidarity is in fact a fundamental principle of Catholic Social Teaching (Pontifical Council for Justice and Peace, 2004, pt. I, ch. 4, §vi) based on, among other sources, the Second Vatican Council’s Pastoral Constitution on the Church in the Modern World (Gaudium et Spes), which asserts that “God did not create man for life in isolation, but for the formation of social unity” (Vatican II, 1965, n. 32). Pope John Paul II (1995, n. 64), in characterizing the “culture of death” he takes to be ever more definitive of the modern social ethos, warns of the utilitarian reduction of the common good to the mere aggregation of preference satisfactions and a commensurate degrading of the value of human life to contributions one can make to their own or others’ preference satisfactions: Here we are faced with one of the more alarming symptoms of the “culture of death” . . . marked by an attitude of excessive preoccupation with efficiency and which sees the growing number of elderly and disabled people as intolerable and too burdensome. These people are very often isolated by their families and by society, which are organized almost exclusively on the basis of criteria of productive efficiency, according to which a hopelessly impaired life no longer has any value. John Paul II also echoes Aquinas’ communitarian argument against suicide insofar as “it involves the rejection of love of self and the renunciation of the obligation of justice and charity towards one’s neighbor, towards the communities to which one belongs, and towards society as a whole” (John Paul II, 1995, n. 66). It would be asking too much, however, to require the terminally ill not to elect suicide, and to instead suffer with fortitude, in the absence of communal support19: The request which arises from the human heart in the supreme confrontation with suffering and death, especially when faced with the temptation to give up in utter desperation, is above all a request for companionship, sympathy and support in the time of trial. It is a plea for help to keep on hoping when all human hopes fail. (John Paul II, 1995, n. 67) The inherently subjective self-assertion that may motivate a suicidal sufferer, as well as preclude compassionate care from his surrounding community, constitutes one aspect of the “dictatorship of relativism” of which Pope Benedict XVI warns, “whose ultimate goal consists solely of one’s own ego and desires” (Benedict XVI, 2005). This culturally pathological self-centeredness leads to a justification of PAS premised on, according to Pope Francis, a “false compassion” that exemplifies the “throwaway culture” typical of modern society in which—harkening back to John Paul II—the materially useless, with respect to the satisfaction of their own or others’ preferences, are considered disposable: “True compassion does not marginalize anyone, nor does it humiliate and exclude—much less considers [sic] the disappearance of a person as a good thing” (Catholic News Agency, 2015). By contrast, authentic compassion ensures “that the sacred value of the life of the patient does not disappear or become obscured, but instead shines with greater splendor precisely in suffering and helplessness” (Catholic News Agency, 2015). Francis’ concern is premised on the distinction between valuing persons, who have incalculable moral value—viz., dignity—and valuing interests, which may be comparatively valued in a utilitarian metric. As Daniel Sulmasy et al. aptly put it, PAS “require[s] us to accept that it is morally permissible to act with the specific intention-in-acting of making a somebody into a nobody, i.e. to make them dead” (Sulmasy et al. 2016, 248–9). Instead, “The terminally ill, especially, need to be reminded of their value, their intrinsic dignity, at a time of fierce doubt. They need to know that their ultimate value does not depend upon their appearance, productivity, or independence” (Sulmasy et al. 2016, 248–9). Sulmasy et al. (2016, 251) further point out the broader communal impact of PAS: Human beings then are always, and essentially a part of a community of persons, and as such because of this connection with others (as part of humanity), when another person kills him- or herself or allows him- or herself to be killed, life for every other human being is cheapened (devalued). This claim implicitly invokes one of the two central principles that ground Cardinal Joseph Bernardin’s promotion of a “consistent ethic of life”: We are not born to live alone, but, rather, to move from the dependency of prenatal life and infancy to the interrelatedness of adulthood. To be human, then, is to be social, and those relationships, structures, and institutions which support us, as individuals and as a community, are an essential aspect of human life. (Bernardin, 2008a, 256) Bernardin (2008b, 161) applies this principle in a similar manner as Sulmasy et al. to highlight the large-scale social cost of legalizing PAS: What would we be suggesting to one another and to our society, if, seemingly with the best of motives, we were to say that those who are sick, infirm, or unconscious may be killed? How could we allege that such actions would not affect us individually and collectively? We may never agree to this kind of privatization of life because, if we were to do so, we would undermine our ability to live in community. Life is both a private and a public good, and, therefore, social legislation to defend and protect it is both appropriate and necessary. Catholic teaching regarding PAS is consistent in invoking the essentially communal dimension of human nature, cohering with the Thomistic Aristotelian concept of human persons as fundamentally “social animals.” This anthropological view undergirds a two-fold set of responsibilities (a) on the part of suffering, dying persons not to assert their autonomy—understood in an individualistic, libertarian sense—by removing themselves from their community and (b) on the part of communities to provide the genuinely compassionate presence of caregivers, and social support for such caregivers, to suffer with the terminally ill so that they may potentially realize various benefits—for themselves, their caregivers, and the wider community—in confronting their physical and existential suffering. In concluding, I will highlight some specific communal responsibilities following from this general moral conclusion. VI. COMMUNAL DUTIES TO THE DYING PERSON Ira Byock (1997, 121) contends that “beyond meeting patients’ most basic human needs, the rudiments of care, the human community possesses an ability to respond to those who are dying that is limited only by its collective imagination.” Reflecting on the alienation alluded to above that a suffering patient may feel due to the frightening and existentially repulsive effect his experience may have on others who are forced to confront their own frailty and mortality, Hauerwas (1986, 26) emphasizes a fundamental dimension of medicine as a “moral art:” It is the burden of those who care for the suffering to know how to teach the suffering that they are not thereby excluded from the human community. In this sense medicine’s primary role is to bind the suffering and the nonsuffering into the same community. Unfortunately, medicine is used too often to guard us from those who suffer. Hauerwas (1986, 106) concludes, in line with what I argue above, that there is mutual responsibility on the part of suffering patients and their caregivers to continue fulfilling moral obligations to each other. Suffering patients are thus not merely passive recipients—as the term “patient” implies—of others’ compassion. Instead, the moral project of authoring the concluding chapter of the narrative of one’s embodied life becomes a collaborative endeavor that involves the continuing autonomous exercise of particular virtues: Our willingness to live in the face of suffering, pain, and sheer boredom of life is morally a service to one another as it is a sign that life can be endured and moreover our living can be done with joy and exuberance. Our obligation to sustain our lives even when they are threatened with, or require living with, a horrible disease is our way of being faithful to the trust that has sustained us in health and now in illness. We take on a responsibility as sick people. That responsibility is simply to keep on living, as it is our way of gesturing to those who care for us that we can be trusted and trust them even in our illness. (Hauerwas, 1986, 106) Alasdair MacIntyre (1999; see also Eberl, 2008) affirms this mutual responsibility as premised on human animality, which entails vulnerability and thereby dependency on others. Each person is called to recognize that, since others depend on him, he must respond to that dependency since he himself was cared for by others in his previous states of dependency. The need to fulfill one’s reciprocal responsibility to care for others is all the more acute when the other is facing the physical and existential suffering that invariably accompanies terminal illness—particularly when it is prolonged. For, as noted above, there is an endemic alienation that occurs as one must come to terms with his own frailty and mortality, which prompts a natural recoil in those who are healthy and must bear witness to this unpleasant reminder of their own inherent vulnerability and probable future dependency. Paul Schotsmans (2003a, 336) reports on this general phenomenon as witnessed in the case of his own dying brother: I also observed the almost total negation of the very close relatives of other patients – not willing to see, refusing to be exposed at all. What shocked me the most was how lonesome it is for a human being to go through this process – all medical and paramedical staff and family members have the chance to go away, to “breathe” in normal life, but the dying patient remains left finally on his own. Even when caregivers do make themselves present to the dying person for a time, they also have the freedom to leave, go home, enjoy respite from their co-suffering, and rejuvenate themselves to return and endure more. The patient himself has no such freedom. Yet, although such existential loneliness cannot be completely obliterated, it can be ameliorated to a certain extent by fostering bonds of intimacy between patients and caregivers such that the latter can trust that the loving concern of the former continues to be present even when the caregiver physically is not (Rawlinson, 1986, 59). It is this loss of trust, which in turn precludes intimacy, of which Callahan warns in highlighting the fundamental change in the nature of human relationships that would result from communally sanctioned PAS. To conclude, what are some practical recommendations for how caregivers may effectively fulfill their responsibilities to the terminally ill in order to foster the various values described above? Unfortunately, integrative models of high-quality palliative care are not yet predominant in the clinical milieu; although such models certainly exist and are staffed by dedicated professional caregivers who provide physical, emotional, and spiritual support to both patients and familial caregivers (Curlin, 2015). Nevertheless, there are some sound, broadly construed recommendations that may provide a helpful framework for a set of “best practices” that should be implemented, analyzed, and continually refined. M. Therese Lysaught (2015, 81), for example, offers the following, admittedly minimal, set of recommendations for moving towards a “tamed death”: • make the dying the principal directors of their own dying process20 • ensure that the dying know that they are dying • enable the dying to take stock of their life, to express both gratitude for the goods of their life as well as sorrow for its closure • integrate practices of reconciliation between patients, their family members and friends, and health care practitioners21 • integrate patients’ communities22 into the dying process • acknowledge and tend to the wounds that death inflicts on patients’ communities. Incorporating such practices, not only within the health care profession, but also within the wider community, is not without its challenges. This is especially the case in societies that are largely averse even to discussing death and associated topics, which hinders, among other things, advance care planning. Lydia Dugdale (2015, 188–9) enumerates five particular challenges to cultivating an ars moriendi—“art of dying”—which would help terminally ill individuals and their surrounding communities to better effectuate the various potential instrumental values discussed above in confronting physical and existential suffering, as well as adequately to reflect on and prepare for how one wants to die: • First, there will always be people who lack the willingness to confront finitude, whether because of deeply held beliefs . . . or because of fear, ignorance, discomfort, or inability to comprehend the incomprehensible. • Second, even among those who admit of life’s limits, there will continue to be many who nevertheless become incapacitated once the subject of death actually presents itself. • Third, community at [familial, societal, and biomedical] levels will be difficult for many to achieve. • Fourth, to the extent that physicians are relied upon in the art of dying, time pressures will hinder effective communication. • Fifth, the only way to cultivate the practice of an art of dying is through personal and community-wide [daily] discipline.23 It is worth noting that some local communities have launched initiatives to help address these challenges. For instance, in Indianapolis and several other cities around the globe, “Death Cafes” provide a casual, non-directive setting in which participants may freely discuss their thoughts, feelings, concerns, and experiences regarding death and dying (Barsky and Barsky, 2017). Also, the Indiana University School of Nursing recently hosted a first-of-its-kind in the United States “Before I Die Festival” comprising various types of events related to death and dying around the city, including film presentations, book discussions, art exhibits, and panel presentations by palliative care teams and other relevant professionals (Stearns, 2016). Furthermore, Eskenazi Hospital in Indianapolis, a publicly-funded hospital serving a large number of indigent patients, sponsors a program called “No One Dies Alone,” in which volunteers spend time with dying patients who have no family or close friends available (Eskenazi Health, 2017). Finally, Angola State Penitentiary in Louisiana has instituted a hospice volunteer program among its inmates to serve those who are dying within the prison while serving their sentence—a unique form of communal care and reconciliation among those who have harmed others in society but yet maintain their inherent dignity as persons created in the imago Dei (Cohen, 2011). Hopefully, these and similar programs being instituted in other communities will provide models for truly compassionate care for the terminally ill, which will help foster actualization of the various potential instrumental values described above when facing suffering and impending death, and thereby provide an individually and communally recognized positive alternative to PAS.24 NOTES 1. Whichever of these terms—“medical aid-in-dying” [MAID] is another—one uses to describe this practice automatically betrays one’s view regarding its ethical legitimacy. Although I aim not to beg any questions at the outset, I have elected to utilize the former term. 2. From a Christian perspective, individuals may also have a duty toward God not to end their life prior to natural death as well as there being a divinely-oriented communal duty not to allow individuals to commit suicide. I will elucidate below, as a representative Christian view, the Roman Catholic Church’s teachings concerning suicide and how both individual and communal duties toward God inveigh against the moral permissibility of suicide, while also promoting the provision of effective means of support to ameliorate the suffering that motivates individuals towards such drastic means of purported self-palliation. 3. Some arguments supportive of PAS also claim that chronically ill persons, or those experiencing existential suffering but who are not imminently dying, ought to be able to avail themselves of PAS (Varelius, 2014). For simplicity, I will refer only to PAS with regard to the terminally ill. However, this discussion will bear on proper care for the chronically ill and existentially suffering as well. 4. Interestingly, data from Oregon’s experience has shown an improvement in physicians’ awareness of palliative care options and the quality of care provided (Ganzini et al., 2000; 2001), which may partially account for why, in a 2004 report, about one-third of patients who received a prescription for PAS in Oregon elected instead to die from the natural progression of their terminal illness (Bascom and Tolle, 2004). Lindsay (2009) has utilized this data to argue for expanded legalization of PAS. Durante (2009) counters that Lindsay does not provide a model of “adequate” palliative care that would alleviate those forms of persistent suffering that still drive some patients to elect PAS, or alternatively demonstrate that such a model would not be possible in principle. In other words, if some patients are still seeking palliation of their suffering by ending their lives, then there are evident inadequacies in either their access to palliative care opportunities or the quality of care received. The question then becomes whether there are principled limitations to even an optimal model of palliative care to ameliorate effectively all forms of a patient’s suffering sufficient for them not to elect PAS. 5. Part of this section is derived from Eberl (2003). 6. For an overview of the ethical imperative to respect substantial autonomy and the criteria utilized to establish whether one’s exercise of autonomy is reasoned and adequately informed, see Chapter 4 of Beauchamp and Childress (2013). 7.. Harris is here referring more broadly to the prohibition of “euthanasia,” which goes beyond PAS to include acts in which a physician or other person directly ends the life of a terminally ill patient either with, or sometimes in the absence of, his autonomous consent. Typically, moral arguments in favor of or against euthanasia will redound to support or condemnation of PAS as well; thus, the two practices will not be treated separately in this discussion. 8. Similarly, emphasizing the meaning of autonomy as “self-ownership,” Craig Paterson concludes, “Since a person cannot alienate his or her radical right to own himself or herself [via voluntary enslavement], a person should not be able to alienate his or her radical right to continue to own himself or herself by means of self-destruction” (Paterson, 2008, 119). 9. For an in-depth presentation of Aquinas’ concept of the “common good” and its Aristotelian foundation, see Keys (2006). Neo-Aristotelian defenses of the common good, and the various particular goods it comprises, can be found in Nussbaum (2011) and MacIntyre (2016, 106–10, 168–74). 10. The translation of Aquinas is my own. The reference to Aristotle is as follows: “Now if someone murders himself because of anger, he does so willingly, in violation of correct reason, when the law forbids it; hence he does injustice. But injustice to whom? Surely to the city, not to himself, since he suffers it willingly, and no one willingly suffers injustice” (Aristotle, 1985, V 11, 1138a10-12). 11. As with most general labels, there are various nuanced versions of “communitarianism” in both moral and political dimensions, not all of which would be shared by Thomistic Aristotelianism. For the purposes of this discussion, particularly since I am not mounting an explicit argument against legalized PAS, communitarianism may be understood here in its broadest sense of being “concerned with moral considerations—values, norms, and virtues—connected with human communities at various levels, from the family, friendships, neighborhood, professional-client relationship, professional associations, social organizations, to society at large, and the state” (Miller, 1997, 79). Miller justifies PAS within a communitarian ethic as a “last resort” when other supportive palliative care measures have been exhausted, but concurs with complaints lodged by Callahan, and myself in what follows, against the standard autonomy- and beneficence-based arguments in favor of PAS. 12. That this is a conceptual distinction for Aquinas and not a mere artifact of translation is evidenced by instances in which Aquinas refers to human beings as both “political” and “social” animals (ST, I-II, q. 72, a. 4). For further elucidation, see Scully (1981). 13. For elucidation of Aquinas’ argument that suicide violates one’s obligation to love oneself, see Eberl (2003). 14. This section is derived from Eberl (2012). For more extensive analyses of the nature of suffering and our moral response to it, see Cassell (2004) and Green and Palpant (2014). 15. The relative percentages for these reasons have held consistently over the years since Oregon’s Death with Dignity Act was enacted in 1997, and hold similarly as well since Washington legalized PAS in 2009 (Emanuel et al., 2016, 85). 16. Note that, by “caregivers,” I am referring not only to health care professionals but also anyone who is present with the patient and provides care in a broadly-construed fashion, which includes family members, friends, pastoral ministers, non-professional volunteers, etc. 17. Although Nietzsche did not harbor much moral consideration for the “weak,” his ethic values active fortitude over passive acquiescence in one’s experience of suffering. 18. For an extensive list of the psychological, emotional, social, economic, and other stresses caregivers may experience, see Callahan (2015, 150–1). 19. To be clear, I am not claiming that there are any morally justifiable reasons for one to elect PAS, but that to contend such without also providing effective support to help ameliorate a patient’s suffering is analogous to a governmental “unfunded mandate” —that is, a command given without the support one needs to adhere to the command. Another way to conceptualize this claim is in terms of the Kantian “ought implies can” principle—viz., that one is bound by a moral duty only to the extent that one is capable of fulfilling said duty. Similarly, one cannot contend that a suffering patient ought to face suffering and impending death with fortitude without also providing the requisite support for the patient to act in a fortitudinous manner. 20. This recommendation could be construed as providing tacit support for PAS; however, it also refers to dying patients having their wishes respected concerning whether certain treatment options should be pursued, whether certain mechanical aids should be utilized or withheld/withdrawn, whether they wish to remain in the hospital or die at home with hospice care, etc. 21. Such practices may be secular or faith-based, involving practices such as mediating intra-familial conflict concerning care decisions, ameliorating moral distress health care practitioners may experience if care decisions are made with which they do not agree—whether involving over- or under-treatment—as well as providing spiritual support—ideally from either a hospital chaplain or a cleric from the patients’ own religious community with whom they have developed a close relationship. 22. Patients’ “communities” here and in the next bullet-point should be understood as one’s most immediate network of social relationships, augmented by support from the wider political community, as elucidated above. 23. Such “community-wide” discipline is best developed and practiced in the context of one’s most immediate network of social relationships, augmented by support from the wider political community, as elucidated above. 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Notre Dame, IN: University of Notre Dame Press. House of Commons of Canada. 2016. Bill C-14: An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying), 42nd Parliament, 1st Sess . [On-line]. Available: http://www.parl.ca/DocumentViewer/en/42-1/bill/C-14/third-reading (accessed December 1, 2017). Hume, D. 1783. Essay on suicide. [On-line]. Available: http://www.davidhume.org/texts/suis.html (accessed December 2, 2017). Humphry, D. 1992. Dying with Dignity. Understanding Euthanasia . New York: Birch Lane Press. John Paul II. 1984. Salvifici doloris . The Holy See [On-line]. Available: https://w2.vatican.va/content/john-paul-ii/en/apost_letters/1984/documents/hf_jp-ii_apl_11021984_salvifici-doloris.html (accessed December 1, 2017). ———. 1995. Evangelium vitae . The Holy See [On-line]. Available: http://w2.vatican.va/content/john-paul-ii/en/encyclicals/documents/hf_jp-ii_enc_25031995_evangelium-vitae.html (accessed December 1, 2017). Kaczor, C. 1998. Faith and reason and physician-assisted suicide . Christian Bioethics  4(2): 183– 201. Kant, I. 1997. Groundwork of the Metaphysics of Morals , trans. M. Gregor. New York: Cambridge University Press. Keys, M. M. 2006. Aquinas, Aristotle, and the Promise of the Common Good . New York: Cambridge University Press. Google Scholar CrossRef Search ADS   Levinas, E. 1988. Useless suffering. In The Provocation of Levinas. Rethinking the Other , eds. R. Bernasconi, and D. Woods, 56– 69. London, United Kingdom: Routledge. Lindsay, R. 2009. Oregon’s experience: Evaluating the record. American Journal of Bioethics  93(1): 19– 27. Google Scholar CrossRef Search ADS   Loewy, E. H. 1991. Suffering and the Beneficent Community. Beyond Libertarianism . Albany, NY: SUNY Press. Lysaught, M. T. 2015. Ritual and practice. In Dying in the Twenty-First Century. Toward a New Ethical Framework for the Art of Dying Well , ed. L. S. Dugdale, 67– 85. Cambridge, MA: MIT Press. 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Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clinic Proceedings  90(12): 1600– 13. Google Scholar CrossRef Search ADS   Stearns, A. 2016. IU School of Nursing hosts Indy’s first “Before I Die” festival . NUVO [On-line]. Available: https://www.nuvo.net/news/news/iu-school-of-nursing-hosts-indy-s-first-before-i/article_cc7b1da1-1b0a-53e2-9b9a-9d4c76ffdf8a.html (accessed December 1, 2017). Stempsey, W. E. 1998. Laying down one’s life for oneself. Christian Bioethics  4(2): 202– 24. Google Scholar CrossRef Search ADS   Sulmasy, D. P., J. M. Travaline, L. A. Mitchell, and E. W. Ely. 2016. Non-faith-based arguments against physician-assisted suicide and euthanasia. The Linacre Quarterly  83(3): 246– 57. Google Scholar CrossRef Search ADS   Varelius, J. 2014. Medical expertise, existential suffering and ending life. Journal of Medical Ethics  40(2): 104– 7. Google Scholar CrossRef Search ADS   Vatican II. 1965. Gaudium et spes . The Holy See [On-line]. Available: http://www.vatican.va/archive/hist_councils/ii_vatican_council/documents/vat-ii_const_19651207_gaudium-et-spes_en.html (accessed December 1, 2017). © The Author(s) 2018. Published by Oxford University Press, on behalf of The Journal of Christian Bioethics, Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Christian Bioethics Oxford University Press

I Am My Brother’s Keeper: Communitarian Obligations to the Dying Person

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Abstract

Abstract Contemporary arguments concerning the permissibility of physician-assisted suicide [PAS], or suicide in general, often rehearse classical arguments over whether individual persons have a fundamental right based on autonomy to determine their own death, or whether the community has a legitimate interest in individual members’ welfare that would prohibit suicide. I explicate historical arguments pertaining to PAS aligned with these poles. I contend that an ethical indictment of PAS entails moral duties on the part of one’s community to provide effective means of ameliorating physical and existential suffering. I further elucidate how such duties have been affirmed by the Roman Catholic Church. My aim is to provide reasons why the expanding legalization of PAS should not preclude social investment in effective palliative care and the provision of a communal presence to the dying as they confront their subjectively experienced suffering. I. INTRODUCTION The past two decades have seen myriad books and articles written by ethicists, moral theologians, lawyers, and sundry other academic scholars and professionals concerning the practice of physician-assisted suicide [PAS] or physician-aid-in-dying [PAD].1 This explosion of scholarship was sparked in the United States by the enactment of Oregon’s Death with Dignity Act in 1997 (Oregon Public Health Division, 2015). Since then, to date, five other US states—Washington, Montana, Vermont, Colorado, and California—and the District of Columbia have legalized PAS in some form or fashion. Furthermore, Canada has recently granted federal approval of PAS (House of Commons of Canada, 2016), and popular debate gained traction with the well-publicized death of Brittany Maynard via PAS (Maynard, 2014). Yet, arguments concerning the ethical or legal permissibility of PAS, or suicide in general, are nothing new; they trace back over 2,500 years in Western philosophical and religious traditions. In fact, today’s popular and scholarly debates often rehearse classical arguments over whether individual persons have a fundamental right based on autonomy to determine their own death, or whether the community in which individuals are unavoidably embedded has a legitimate interest in their welfare that would prohibit suicide—with or without the assistance of medical professionals.2 I will explicate some of the historical arguments that pertain to the contemporary debate over PAS aligned with the poles of individual autonomy versus communal interest. I contend that an ethical indictment of PAS does not merely negate a terminally ill person’s putative freedom to end his life,3 but entails moral duties on the part of his surrounding community—defined in various levels as discussed below—to provide effective means of ameliorating his physical and existential suffering. I will elucidate how such duties have been affirmed by one of the foremost voices opposing PAS: the Roman Catholic Church. I will not specifically argue here against the legalization of PAS, though the claims affirmed herein could be utilized to construct such an argument and Christians have well-argued reasons to stand in opposition to PAS (Grisez and Boyle, 1979). Rather, my aim is to provide reasons why the expanding legalization of PAS should not preclude social investment in effective palliative care and overall caregiving, providing a communal presence to the dying as they confront their subjectively experienced suffering.4 II. LIBERTARIAN AND COMMUNITARIAN ARGUMENTS REGARDING PAS5 A prominent argument in favor of the moral and legal permissibility of PAS is based on a fundamental ethical imperative to respect the informed, reasoned choices of substantially autonomous individuals.6 In overturning a legal prohibition on PAS in the state of Washington, US District Judge Barbara Rothstein contends, “There is no more profoundly personal decision, nor one which is closer to the heart of personal liberty, than the choice which a terminally ill person makes to end his or her suffering and hasten an inevitable death” (Compassion in Dying, 1996). John Harris goes so far as to condemn laws prohibiting PAS7 as “tyrannous” insofar as such laws “deny a person control of what, on any analysis, must be one of the most important decisions of life . . . which like all acts of tyranny is an ultimate denial of respect for persons” (Harris, 1995, 19–20). This categorization implicitly invokes John Stuart Mill’s declaration of the inherent “sovereignty” mature persons have over their own minds and bodies, which merits a fundamental respect in the absence of a compelling communal interest in preventing harm to others (Mill, 1869, I 9). Mill nevertheless supports legal prohibitions on acts that would, even if voluntarily entered into, nullify one’s liberty—such as selling oneself into slavery or risking one’s life in a duel. Regarding the former, Mill (1869, V 11) states, The reason for not interfering, unless for the sake of others, with a person’s voluntary acts, is consideration for his liberty . . . But by selling himself for a slave, he abdicates his liberty; he foregoes any future use of it beyond that single act . . . The principle of freedom cannot require that he should be free not to be free. It is not freedom, to be allowed to alienate his freedom. Mill’s valuation of liberty entails equal valuation of the necessary conditions for one’s exercise of liberty, the foundation of which is one’s life. As Christopher Kaczor contends, “Since all liberty rights arise from the right to life, one simply cannot have a liberty right to end one’s life, for this would be to undermine the original source of the liberty right” (Kaczor, 1998, 198).8 In contrast to Mill’s libertarian account, Immanuel Kant (1997) conceptualizes autonomy not as the exercise of an individual’s will without internal or external constraints, but rather as the will’s capacity to self-legislate—that is, to govern oneself in accordance with the rationally understood moral law. The exercise of self-legislation, however, includes “an implicit communal dimension that recognizes a shared interest or law . . . that treats all people as ends [in themselves] . . . Kant’s autonomy implicitly involves a relational component” (Ridenour and Cahill, 2015, 114). This Kantian understanding of the role of autonomy aligns with the more classical views of Aristotle and Thomas Aquinas, both of whom consider individuals to be inextricably members of a community. As such, certain natural limits are imposed on an individual’s exercise of his moral agency in light of demands of the common good. The common good is not merely the aggregate of satisfied preferences across a majority of individuals. Rather, this concept signifies mutual individual and collective flourishing: Individuals only flourish within a community, and the flourishing of a community should redound to that of each individual member thereof.9 In relation to the case at hand, Aquinas draws on Aristotle in one of his three indictments against suicide: “every part as such, is of the whole. Now every man is part of the community: and so as such, is of the community. Hence in the case that he kills himself, he causes injury to the community” (Summa Theologiae [ST], II-II, q. 64, a. 5).10 All human persons are interrelated in variously defined political communities. We can also be said to belong to one overall human community, which transcends nation, race, and gender boundaries. As a result of this conception of human nature, one that is essentially communitarian, Aquinas holds that each individual human person is responsible not only to himself, but also to every other member of the human community.11 Thus, suicide is not a purely private action with implications only for the suicidal agent. There are, of course, multiple levels of human communities, so it is important to ask to which level of community one owes a duty not to commit suicide, and thus conversely which level of community owes its members supportive care to ameliorate their suffering such that suicide becomes less of a considered option. For Aquinas (2007, I 2), following Aristotle, it was the polis—that is, the state—which is charged with crafting legislation aimed at helping its constituent citizens to flourish as living, sentient, social, and rational animals. Scully notes that the function of the state is to design laws that serve the well-being of the body politic “by promoting an environment in which local communities, families and individuals may subsist and develop as human, rational, moral beings” (Scully, 1981, 428). The polis comprises multiple forms of smaller social communities—for example, households, clans, and villages—as well as ecclesiastical communities—for example, parishes, dioceses, and religious orders—and other forms of association—for example, confraternities and guilds. It is noteworthy that, although Aquinas follows Aristotle in defining human beings as essentially “political animals,” he also distinctively refers to human beings in certain contexts as “social animals” (see ST, I, q. 96, a. 4; ST, I-II, q. 61, a. 5; ST, I-II, q. 95, a. 4; ST, II-II, q. 114, a. 2 ad 1; ST, III, q. 65, a. 1).12 In line with the principle of Catholic Social Teaching known as subsidiarity (Pontifical Council for Justice and Peace, 2004, pt. I, ch. 4, §iv), whereas an individual’s negative obligation not to commit suicide is with respect to the larger political community, there is a corresponding positive obligation on the part of one’s more closely-delineated social community (or communities) to assist one in meeting one’s negative obligation: “Since a human being is a social animal, one human being naturally owes to another whatever without which the conservation of human society would not be possible” (ST, II-II, q. 109, a. 3 ad 1; Aroney, 2007). If, as Aquinas argues, the conservation of human society requires individual members not to commit suicide, then such individuals are owed by others within society whatever assistance they need not to consider such a drastic option. Those who are closest in relationship to such an individual are, pragmatically speaking, typically in the optimal position to provide such assistance. Hence, this positive obligation falls, in addition to one’s professional caregivers, primarily on the shoulders of one’s social networks of family, friends, church community, neighbors, etc., with the circle of responsibility growing wider as more immediate caregivers require additional support to provide the needed assistance—for example, paid time off of work provided by employers, social security and disability benefits, and other forms of political assistance. David Hume (1783) counters each of Aquinas’ indictments of suicide, contending—also in anticipation of one of Kant’s (1997) arguments against suicide—that there is no rational basis for construing suicide as a violation of a moral duty to oneself.13 He further argues that it is unreasonable to view suicide as detrimental to the common good: A man who retires from life does no harm to society: He only ceases to do good; which, if it is an injury, is of the lowest kind. All our obligations to do good to society seem to imply something reciprocal. I receive the benefits of society, and therefore ought to promote its interests; but when I withdraw myself altogether from society, can I be bound any longer? But allowing that our obligations to do good were perpetual, they have certainly some bounds; I am not obliged to do a small good to society at the expence of a great harm to myself; why then should I prolong a miserable existence, because of some frivolous advantage which the public may perhaps receive from me? (Hume, 1783) In contrast to Hume’s conceptualization, David Novak (1975, 66) stresses Aquinas’ view of the reciprocal responsibility between an individual and the community in which he lives: “the person owes the community loyalty and service in return for the just distribution of society’s goods he has received.” The set of “goods” a community owes to its members is what counts toward the fulfillment of their nature—that is, what satisfies their natural desires. Such goods include not only the fundamental good of life, but also various other goods that need to be cultivated within a person in order that he may live to the fullest extent of his nature. Novak (1975, 66) cites certain virtues as examples: “In a true communion of persons one can see a need for even the helpless and infirm. Their very presence enables us to practice the human virtues of benevolence and generosity.” Even a “helpless and infirm” member of a community can remain a contributing member by assisting others in the cultivation of fulfilling goods, while at the same time preserving the fundamental good of his own existence. Every community owes its members this capacity to be of such service to others and to be served by others in return. Hence, it would violate a community’s basic duty to its citizens if it permitted some to view themselves as useless, non-contributing members, for such would not be the truth of the matter. PAS, even more so than unassisted suicide, points to the inescapably relational dimension of the act undertaken: “Euthanasia and PAS are not private matters of self-determination. They are acts that require two people to make either act possible and a complicit society to make either act acceptable” (Callahan, 1997, 76). Callahan (2000, 115–6) thus contends that, not only does respect for the individual right of self-determination not entail allowing for PAS, but also the practice of PAS obviates communal obligations to suffering members: By assuming that the relief of suffering is a goal important enough to legitimate killing as a way of achieving it, we corrupt the idea of such relief as a social good and duty. We cease helping to bear one another’s suffering, but eliminate altogether the person who suffers. We thereby jeopardize both the future of self-determination and the kind of community that furthers its members’ capacity to bear one another’s suffering. Why bear what can be eliminated altogether? For the sake of controlling the conditions of death, we would introduce a fundamental change in the conditions of living a life. In the name of controlling our mortality, we would enter a claim to change the nature of human relationships. If PAS violates the reciprocal responsibilities between individuals and their communities in service of the common good, what alternative courses of action would fulfill these responsibilities, and what specific goods should they promote? III. ADDRESSING THE NEEDS OF THE DYING14 In addition to a liberal, individualistic conception of autonomy and a putative ethical mandate to acquiesce to the informed, reasoned choices of terminally ill persons, probably the most influential argument in favor of PAS is that it is a function of the medical profession’s fundamental duty of beneficence to alleviate suffering. Of course, pain may often—though not always barring complete sedation—be treated effectively by analgesic medication. Suffering, however, comprises more than pain to include other physical, existential, social, and psychological burdens, such as the loss of independence, sense of self, and functional capacities that some persons feel jeopardize their dignity. PAS is argued to be a compassionate response to such unremitting physical and existential suffering. In fact, pain and other physical symptoms are not among the primary reasons cited for requesting PAS. In Oregon, the three most frequently mentioned end-of-life concerns are loss of autonomy (91.4%), decreasing ability to participate in activities that made life enjoyable (86.7%), and loss of dignity (71.4%) (Oregon Public Health Division, 2015, 5).15 As an alternative to PAS, I contend that the presence of loving caregivers can assist terminally ill patients with respect to these more commonly cited dimensions of their overall experience of existential suffering. Although not all patients will find meaning or value in their suffering as they approach the end of life, the question must be explored whether PAS is being promoted as an option prior to having exhausted all other communal caregiving opportunities to help patients potentially derive meaning or value from their remaining natural lifetime. Although suffering has no intrinsic value, there are a number of religious and secular reasons why suffering patients may potentially find their suffering to have an instrumental value. The opportunity to explore this potential is occluded by a premature offering of PAS as the only or most choiceworthy means of optimizing a “good death” or a “death with dignity.” Although the former term is the literal translation of the Greek root of “euthanasia”—eu-thanatos—and the latter term is the hallmark catch-phrase of PAS proponents (Humphry, 1992), the concept of a dignified death does not entail moral advocacy for PAS depending on how one defines the ambiguous concept of “dignity” in relation to human persons. I will describe various ways in which terminally ill patients may exemplify their dignity, understood in a Thomistic Aristotelian sense, as they confront physical and existential suffering (Gentzler, 2003). Among various religious traditions is the view that suffering may be redemptive in the sense of serving to attain some larger social or higher spiritual good. For example, within the Christian tradition, Pope John Paul II (1984, n. 19) contends, In the Cross of Christ not only is the Redemption accomplished through suffering, but also human suffering itself has beenredeemed . . . Every man has his own share in the Redemption. Each one is also called to share in that suffering through which the Redemption was accomplished . . . each man, in his suffering, can also become a sharer in the redemptive suffering of Christ. Suffering may also be understood as a source of repentance and atonement for past moral wrongdoing, both as a precursor to the temporal suffering one may endure in purgatory, with its spiritually purifying effect, and as a source of spiritual healing prior to death: “Suffering must be for conversion, that is, for the rebuilding of goodness in the [sufferer], who can recognize the divine mercy in this call to repentance” (John Paul II, 1984, n. 12; Fernandes, 2001). Less punitively, suffering could constitute a trial by means of which the patient is able to cultivate or exercise certain laudable traits of moral character: Suffering as it were contains a special call to the virtue which man must exercise on his own part. And this is the virtue of perseverance in bearing whatever disturbs and causes harm. In doing this, the individual unleashes hope, which maintains in him the conviction that suffering will not get the better of him, that it will not deprive him of his dignity as a human being, a dignity linked to awareness of the meaning of life. (John Paul II, 1984, n. 23) William Stempsey invokes the example of a marathon runner at the 1996 Olympic Games who injured himself but continued limping to the finish line, finally reaching it ninety minutes after the previous finisher to the applause of a crowd who faithfully remained to witness this display of courage and perseverance: “The admiration we feel for those who persevere in the face of great pain should tell us something about the moral goodness of those who reject suicide in the face of great suffering” (Stempsey, 1998, 214). This does not entail that those who fail to display such heroic virtues should be morally condemned. Rather, the point is that there is significant potential value that one may derive from their experience of suffering, an opportunity which PAS inherently denies. The exercise of virtues such as perseverance and hope may not only empower the suffering patient, but may serve as a powerful witness to caregivers16: When this body is gravely ill, totally incapacitated, and the person is almost incapable of living and acting, all the more do interior maturity and spiritual greatness become evident, constituting a touching lesson to those who are healthy and normal. (John Paul II, 1984, n. 26) To be clear, it is not being recommended that patients be forced to suffer merely as a means for the sake of providing a moral lesson for their caregivers. However, when suffering must unavoidably be endured—short of ending one’s life—then the possibility of the suffering patient serving as such a witness could help him to discover meaning and value in his continued existence, instead of experiencing himself as powerless, alone, and a burden on his caregivers. There are also several non-religiously based perspectives on physical and existential suffering’s potential instrumental value. First, echoing one of John Paul II’s claims above, how patients respond to their own suffering could constitute a source for developing and actualizing one’s moral character: “In our response to the mystery of suffering, we define ourselves, find our integrity and ultimately shape our ethos” (Fleischer, 1999, 485). Callahan (2000, 149) contends that how a terminally ill patient “masters” his dying exemplifies how he has lived his life: “How we die will be an expression of how we have wanted to live, and the meaning we find in our dying is likely to be at one with the meaning we have found in our living.” Far from suffering entailing passive weakness, confronting it could be means of transcendence in the Nietzschean sense of “overcoming” oneself into a “higher order” of humanity through effort and striving—not avoiding distress, but rather knowing it as an essential condition of one’s animal condition (Nietzsche, 2001, I 48 passim).17 How one responds to suffering is also an exercise of autonomy: “When I have options to my suffering, suffering is greatly reduced. A sense of impotence, a lack of control over my own destiny, aggravates suffering or, sometimes, can convert pain to suffering” (Loewy, 1991, 11). Of course, having PAS as a legal option expands one’s range of what may be autonomously chosen. Yet, in one statewide survey in Oregon, approximately a third of individuals who had PAS as a legal option instead autonomously elected to persist to the natural end of their lives; interviews suggested that possessing the lethal prescription may have provided them with “a sufficient sense of control” (Bascom and Tolle, 2004, 87). Although it may seem irrational on the surface for someone who possesses autonomously chosen means to end their suffering to elect not to do so, Stanley Hauerwas (1986, 33–4) counters that suffering is actually an essential ingredient for the exercise of autonomy: [W]e only gain autonomy by our willingness to make suffering our own through its incorporation into our moral projects. For autonomy is a correlative of our having a narrative through which we can make our suffering our own. Insofar as medicine denies us our suffering, rather than being a way to regain autonomy, it can be a threat or temptation to lose our autonomy. In addition to promoting individual autonomy, Marsha Fowler (1996, 49) argues that the shared experience of suffering among patients and their caregivers may become a source of solidarity: We do define ourselves in suffering both as individuals and as participants in the shared human condition . . . It is in suffering that we sense profoundly that our afflictedness at once is both intensely private and isolative, and yet held in common with all humanity. Our creatureliness, our lack of control, our consanguinity, our individuality and our co-humanity confront us in suffering . . . Suffering is not ours to control in the sense of its random intrusion into our lives. It is ours to control in terms of how we respond to it individually and collectively. Creating bonds of solidarity is essential to proper caregiving since the inherent nature of suffering unavoidably results in a degree of separation from the community of healthy persons surrounding oneself: Suffering, in a sense, separates persons from community. Suffering persons tend to withdraw into themselves and to feel alienated from a community going on with its daily lives and tasks while they suffer. When communities ignore those within their embrace who are suffering and when they treat them uncaringly or callously the integrity and solidarity of community is shattered. (Loewy, 1991, 13) Finally, although the promotion of meaning and value for the suffering patient should be the community’s paramount concern, a valuable by-product of the provision of proper communal attention is the effect it may have on the cultivation and exercise of virtue among caregivers. Emmanuel Levinas (1988), invoking the ethic of alterity popularized by Martin Buber (1970), exhorts that suffering teaches us to care for others and endows whatever suffering we may experience in providing such care with meaning. It is crucial to emphasize that caring for suffering others does not entail merely empathy or sympathy, but requires being present with them: The compassionate person is not removed from the suffering of the other – there is no distance between them . . . The person who is compassionate before and with the sufferer enters into their suffering, shares in it, and helps to bear the cross endured . . . He is available, present, consoling, and suffers in solidarity with the sufferer. In his compassionate presence as a co-sufferer love deepens the relationship and illuminates the meaning and purpose of suffering. (Nichols, 2013, 382–3; cf. Fowler, 1996, 52) It must be acknowledged that this call to “co-suffer” in solidarity with patients places great stress on caregivers, professional and otherwise, particularly if the patient’s illness persists for months or even years.18 Thus, the supportive net of caregiving must extend outward to encompass others who offer care for a patient’s immediate caregivers, whether through communal volunteer efforts—for example, respite care provided by volunteers from one’s church home—or governmental support mechanisms—for example, protected time off of work under the US Family Medical Leave Act; not to mention more appropriate work-hours, compensation, and mental health support for health care professionals who experience disproportionately high rates of burnout compared to those in other professions (Shanafelt et al., 2015). In the following sections, I will illuminate how the Roman Catholic Church and other scholars advocating a broadly communitarian ethic have reinforced this call to provide effective and authentically compassionate responses to suffering as an alternative to PAS. IV. CATHOLIC MORAL PERSPECTIVE CONCERNING PAS The Roman Catholic Church’s moral condemnation of PAS is based in large part on Aquinas’ arguments against suicide, particularly his third indictment, which is premised on a theological understanding that all human persons are ultimately subject to God (ST II-II, q. 64, a. 5). In its most definitive statement regarding PAS, the Vatican’s Congregation for the Doctrine of the Faith concludes: Human life is the basis of all goods, and is the necessary source and condition of every human activity and of all society. Most people regard life as something sacred and hold that no one may dispose of it at will, but believers see in life something greater, namely, a gift of God’s love, which they are called upon to preserve and make fruitful . . . Intentionally causing one’s own death, or suicide, is therefore 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 also often a refusal of love for self, the denial of a natural instinct to live, a flight from the duties of justice and charity owed to one’s neighbor, to various communities or to the whole of society – although, as is generally recognized, at times there are psychological factors present that can diminish responsibility or even completely remove it. (Congregation for the Doctrine of the Faith, 1980) This argument is based not so much on God’s “ownership” of human lives, but on the consequent call to proper “stewardship” of one’s embodied life, which has an inherently relational, communitarian dimension (Schotsmans, 2003b). Solidarity is in fact a fundamental principle of Catholic Social Teaching (Pontifical Council for Justice and Peace, 2004, pt. I, ch. 4, §vi) based on, among other sources, the Second Vatican Council’s Pastoral Constitution on the Church in the Modern World (Gaudium et Spes), which asserts that “God did not create man for life in isolation, but for the formation of social unity” (Vatican II, 1965, n. 32). Pope John Paul II (1995, n. 64), in characterizing the “culture of death” he takes to be ever more definitive of the modern social ethos, warns of the utilitarian reduction of the common good to the mere aggregation of preference satisfactions and a commensurate degrading of the value of human life to contributions one can make to their own or others’ preference satisfactions: Here we are faced with one of the more alarming symptoms of the “culture of death” . . . marked by an attitude of excessive preoccupation with efficiency and which sees the growing number of elderly and disabled people as intolerable and too burdensome. These people are very often isolated by their families and by society, which are organized almost exclusively on the basis of criteria of productive efficiency, according to which a hopelessly impaired life no longer has any value. John Paul II also echoes Aquinas’ communitarian argument against suicide insofar as “it involves the rejection of love of self and the renunciation of the obligation of justice and charity towards one’s neighbor, towards the communities to which one belongs, and towards society as a whole” (John Paul II, 1995, n. 66). It would be asking too much, however, to require the terminally ill not to elect suicide, and to instead suffer with fortitude, in the absence of communal support19: The request which arises from the human heart in the supreme confrontation with suffering and death, especially when faced with the temptation to give up in utter desperation, is above all a request for companionship, sympathy and support in the time of trial. It is a plea for help to keep on hoping when all human hopes fail. (John Paul II, 1995, n. 67) The inherently subjective self-assertion that may motivate a suicidal sufferer, as well as preclude compassionate care from his surrounding community, constitutes one aspect of the “dictatorship of relativism” of which Pope Benedict XVI warns, “whose ultimate goal consists solely of one’s own ego and desires” (Benedict XVI, 2005). This culturally pathological self-centeredness leads to a justification of PAS premised on, according to Pope Francis, a “false compassion” that exemplifies the “throwaway culture” typical of modern society in which—harkening back to John Paul II—the materially useless, with respect to the satisfaction of their own or others’ preferences, are considered disposable: “True compassion does not marginalize anyone, nor does it humiliate and exclude—much less considers [sic] the disappearance of a person as a good thing” (Catholic News Agency, 2015). By contrast, authentic compassion ensures “that the sacred value of the life of the patient does not disappear or become obscured, but instead shines with greater splendor precisely in suffering and helplessness” (Catholic News Agency, 2015). Francis’ concern is premised on the distinction between valuing persons, who have incalculable moral value—viz., dignity—and valuing interests, which may be comparatively valued in a utilitarian metric. As Daniel Sulmasy et al. aptly put it, PAS “require[s] us to accept that it is morally permissible to act with the specific intention-in-acting of making a somebody into a nobody, i.e. to make them dead” (Sulmasy et al. 2016, 248–9). Instead, “The terminally ill, especially, need to be reminded of their value, their intrinsic dignity, at a time of fierce doubt. They need to know that their ultimate value does not depend upon their appearance, productivity, or independence” (Sulmasy et al. 2016, 248–9). Sulmasy et al. (2016, 251) further point out the broader communal impact of PAS: Human beings then are always, and essentially a part of a community of persons, and as such because of this connection with others (as part of humanity), when another person kills him- or herself or allows him- or herself to be killed, life for every other human being is cheapened (devalued). This claim implicitly invokes one of the two central principles that ground Cardinal Joseph Bernardin’s promotion of a “consistent ethic of life”: We are not born to live alone, but, rather, to move from the dependency of prenatal life and infancy to the interrelatedness of adulthood. To be human, then, is to be social, and those relationships, structures, and institutions which support us, as individuals and as a community, are an essential aspect of human life. (Bernardin, 2008a, 256) Bernardin (2008b, 161) applies this principle in a similar manner as Sulmasy et al. to highlight the large-scale social cost of legalizing PAS: What would we be suggesting to one another and to our society, if, seemingly with the best of motives, we were to say that those who are sick, infirm, or unconscious may be killed? How could we allege that such actions would not affect us individually and collectively? We may never agree to this kind of privatization of life because, if we were to do so, we would undermine our ability to live in community. Life is both a private and a public good, and, therefore, social legislation to defend and protect it is both appropriate and necessary. Catholic teaching regarding PAS is consistent in invoking the essentially communal dimension of human nature, cohering with the Thomistic Aristotelian concept of human persons as fundamentally “social animals.” This anthropological view undergirds a two-fold set of responsibilities (a) on the part of suffering, dying persons not to assert their autonomy—understood in an individualistic, libertarian sense—by removing themselves from their community and (b) on the part of communities to provide the genuinely compassionate presence of caregivers, and social support for such caregivers, to suffer with the terminally ill so that they may potentially realize various benefits—for themselves, their caregivers, and the wider community—in confronting their physical and existential suffering. In concluding, I will highlight some specific communal responsibilities following from this general moral conclusion. VI. COMMUNAL DUTIES TO THE DYING PERSON Ira Byock (1997, 121) contends that “beyond meeting patients’ most basic human needs, the rudiments of care, the human community possesses an ability to respond to those who are dying that is limited only by its collective imagination.” Reflecting on the alienation alluded to above that a suffering patient may feel due to the frightening and existentially repulsive effect his experience may have on others who are forced to confront their own frailty and mortality, Hauerwas (1986, 26) emphasizes a fundamental dimension of medicine as a “moral art:” It is the burden of those who care for the suffering to know how to teach the suffering that they are not thereby excluded from the human community. In this sense medicine’s primary role is to bind the suffering and the nonsuffering into the same community. Unfortunately, medicine is used too often to guard us from those who suffer. Hauerwas (1986, 106) concludes, in line with what I argue above, that there is mutual responsibility on the part of suffering patients and their caregivers to continue fulfilling moral obligations to each other. Suffering patients are thus not merely passive recipients—as the term “patient” implies—of others’ compassion. Instead, the moral project of authoring the concluding chapter of the narrative of one’s embodied life becomes a collaborative endeavor that involves the continuing autonomous exercise of particular virtues: Our willingness to live in the face of suffering, pain, and sheer boredom of life is morally a service to one another as it is a sign that life can be endured and moreover our living can be done with joy and exuberance. Our obligation to sustain our lives even when they are threatened with, or require living with, a horrible disease is our way of being faithful to the trust that has sustained us in health and now in illness. We take on a responsibility as sick people. That responsibility is simply to keep on living, as it is our way of gesturing to those who care for us that we can be trusted and trust them even in our illness. (Hauerwas, 1986, 106) Alasdair MacIntyre (1999; see also Eberl, 2008) affirms this mutual responsibility as premised on human animality, which entails vulnerability and thereby dependency on others. Each person is called to recognize that, since others depend on him, he must respond to that dependency since he himself was cared for by others in his previous states of dependency. The need to fulfill one’s reciprocal responsibility to care for others is all the more acute when the other is facing the physical and existential suffering that invariably accompanies terminal illness—particularly when it is prolonged. For, as noted above, there is an endemic alienation that occurs as one must come to terms with his own frailty and mortality, which prompts a natural recoil in those who are healthy and must bear witness to this unpleasant reminder of their own inherent vulnerability and probable future dependency. Paul Schotsmans (2003a, 336) reports on this general phenomenon as witnessed in the case of his own dying brother: I also observed the almost total negation of the very close relatives of other patients – not willing to see, refusing to be exposed at all. What shocked me the most was how lonesome it is for a human being to go through this process – all medical and paramedical staff and family members have the chance to go away, to “breathe” in normal life, but the dying patient remains left finally on his own. Even when caregivers do make themselves present to the dying person for a time, they also have the freedom to leave, go home, enjoy respite from their co-suffering, and rejuvenate themselves to return and endure more. The patient himself has no such freedom. Yet, although such existential loneliness cannot be completely obliterated, it can be ameliorated to a certain extent by fostering bonds of intimacy between patients and caregivers such that the latter can trust that the loving concern of the former continues to be present even when the caregiver physically is not (Rawlinson, 1986, 59). It is this loss of trust, which in turn precludes intimacy, of which Callahan warns in highlighting the fundamental change in the nature of human relationships that would result from communally sanctioned PAS. To conclude, what are some practical recommendations for how caregivers may effectively fulfill their responsibilities to the terminally ill in order to foster the various values described above? Unfortunately, integrative models of high-quality palliative care are not yet predominant in the clinical milieu; although such models certainly exist and are staffed by dedicated professional caregivers who provide physical, emotional, and spiritual support to both patients and familial caregivers (Curlin, 2015). Nevertheless, there are some sound, broadly construed recommendations that may provide a helpful framework for a set of “best practices” that should be implemented, analyzed, and continually refined. M. Therese Lysaught (2015, 81), for example, offers the following, admittedly minimal, set of recommendations for moving towards a “tamed death”: • make the dying the principal directors of their own dying process20 • ensure that the dying know that they are dying • enable the dying to take stock of their life, to express both gratitude for the goods of their life as well as sorrow for its closure • integrate practices of reconciliation between patients, their family members and friends, and health care practitioners21 • integrate patients’ communities22 into the dying process • acknowledge and tend to the wounds that death inflicts on patients’ communities. Incorporating such practices, not only within the health care profession, but also within the wider community, is not without its challenges. This is especially the case in societies that are largely averse even to discussing death and associated topics, which hinders, among other things, advance care planning. Lydia Dugdale (2015, 188–9) enumerates five particular challenges to cultivating an ars moriendi—“art of dying”—which would help terminally ill individuals and their surrounding communities to better effectuate the various potential instrumental values discussed above in confronting physical and existential suffering, as well as adequately to reflect on and prepare for how one wants to die: • First, there will always be people who lack the willingness to confront finitude, whether because of deeply held beliefs . . . or because of fear, ignorance, discomfort, or inability to comprehend the incomprehensible. • Second, even among those who admit of life’s limits, there will continue to be many who nevertheless become incapacitated once the subject of death actually presents itself. • Third, community at [familial, societal, and biomedical] levels will be difficult for many to achieve. • Fourth, to the extent that physicians are relied upon in the art of dying, time pressures will hinder effective communication. • Fifth, the only way to cultivate the practice of an art of dying is through personal and community-wide [daily] discipline.23 It is worth noting that some local communities have launched initiatives to help address these challenges. For instance, in Indianapolis and several other cities around the globe, “Death Cafes” provide a casual, non-directive setting in which participants may freely discuss their thoughts, feelings, concerns, and experiences regarding death and dying (Barsky and Barsky, 2017). Also, the Indiana University School of Nursing recently hosted a first-of-its-kind in the United States “Before I Die Festival” comprising various types of events related to death and dying around the city, including film presentations, book discussions, art exhibits, and panel presentations by palliative care teams and other relevant professionals (Stearns, 2016). Furthermore, Eskenazi Hospital in Indianapolis, a publicly-funded hospital serving a large number of indigent patients, sponsors a program called “No One Dies Alone,” in which volunteers spend time with dying patients who have no family or close friends available (Eskenazi Health, 2017). Finally, Angola State Penitentiary in Louisiana has instituted a hospice volunteer program among its inmates to serve those who are dying within the prison while serving their sentence—a unique form of communal care and reconciliation among those who have harmed others in society but yet maintain their inherent dignity as persons created in the imago Dei (Cohen, 2011). Hopefully, these and similar programs being instituted in other communities will provide models for truly compassionate care for the terminally ill, which will help foster actualization of the various potential instrumental values described above when facing suffering and impending death, and thereby provide an individually and communally recognized positive alternative to PAS.24 NOTES 1. Whichever of these terms—“medical aid-in-dying” [MAID] is another—one uses to describe this practice automatically betrays one’s view regarding its ethical legitimacy. Although I aim not to beg any questions at the outset, I have elected to utilize the former term. 2. From a Christian perspective, individuals may also have a duty toward God not to end their life prior to natural death as well as there being a divinely-oriented communal duty not to allow individuals to commit suicide. I will elucidate below, as a representative Christian view, the Roman Catholic Church’s teachings concerning suicide and how both individual and communal duties toward God inveigh against the moral permissibility of suicide, while also promoting the provision of effective means of support to ameliorate the suffering that motivates individuals towards such drastic means of purported self-palliation. 3. Some arguments supportive of PAS also claim that chronically ill persons, or those experiencing existential suffering but who are not imminently dying, ought to be able to avail themselves of PAS (Varelius, 2014). For simplicity, I will refer only to PAS with regard to the terminally ill. However, this discussion will bear on proper care for the chronically ill and existentially suffering as well. 4. Interestingly, data from Oregon’s experience has shown an improvement in physicians’ awareness of palliative care options and the quality of care provided (Ganzini et al., 2000; 2001), which may partially account for why, in a 2004 report, about one-third of patients who received a prescription for PAS in Oregon elected instead to die from the natural progression of their terminal illness (Bascom and Tolle, 2004). Lindsay (2009) has utilized this data to argue for expanded legalization of PAS. Durante (2009) counters that Lindsay does not provide a model of “adequate” palliative care that would alleviate those forms of persistent suffering that still drive some patients to elect PAS, or alternatively demonstrate that such a model would not be possible in principle. In other words, if some patients are still seeking palliation of their suffering by ending their lives, then there are evident inadequacies in either their access to palliative care opportunities or the quality of care received. The question then becomes whether there are principled limitations to even an optimal model of palliative care to ameliorate effectively all forms of a patient’s suffering sufficient for them not to elect PAS. 5. Part of this section is derived from Eberl (2003). 6. For an overview of the ethical imperative to respect substantial autonomy and the criteria utilized to establish whether one’s exercise of autonomy is reasoned and adequately informed, see Chapter 4 of Beauchamp and Childress (2013). 7.. Harris is here referring more broadly to the prohibition of “euthanasia,” which goes beyond PAS to include acts in which a physician or other person directly ends the life of a terminally ill patient either with, or sometimes in the absence of, his autonomous consent. Typically, moral arguments in favor of or against euthanasia will redound to support or condemnation of PAS as well; thus, the two practices will not be treated separately in this discussion. 8. Similarly, emphasizing the meaning of autonomy as “self-ownership,” Craig Paterson concludes, “Since a person cannot alienate his or her radical right to own himself or herself [via voluntary enslavement], a person should not be able to alienate his or her radical right to continue to own himself or herself by means of self-destruction” (Paterson, 2008, 119). 9. For an in-depth presentation of Aquinas’ concept of the “common good” and its Aristotelian foundation, see Keys (2006). Neo-Aristotelian defenses of the common good, and the various particular goods it comprises, can be found in Nussbaum (2011) and MacIntyre (2016, 106–10, 168–74). 10. The translation of Aquinas is my own. The reference to Aristotle is as follows: “Now if someone murders himself because of anger, he does so willingly, in violation of correct reason, when the law forbids it; hence he does injustice. But injustice to whom? Surely to the city, not to himself, since he suffers it willingly, and no one willingly suffers injustice” (Aristotle, 1985, V 11, 1138a10-12). 11. As with most general labels, there are various nuanced versions of “communitarianism” in both moral and political dimensions, not all of which would be shared by Thomistic Aristotelianism. For the purposes of this discussion, particularly since I am not mounting an explicit argument against legalized PAS, communitarianism may be understood here in its broadest sense of being “concerned with moral considerations—values, norms, and virtues—connected with human communities at various levels, from the family, friendships, neighborhood, professional-client relationship, professional associations, social organizations, to society at large, and the state” (Miller, 1997, 79). Miller justifies PAS within a communitarian ethic as a “last resort” when other supportive palliative care measures have been exhausted, but concurs with complaints lodged by Callahan, and myself in what follows, against the standard autonomy- and beneficence-based arguments in favor of PAS. 12. That this is a conceptual distinction for Aquinas and not a mere artifact of translation is evidenced by instances in which Aquinas refers to human beings as both “political” and “social” animals (ST, I-II, q. 72, a. 4). For further elucidation, see Scully (1981). 13. For elucidation of Aquinas’ argument that suicide violates one’s obligation to love oneself, see Eberl (2003). 14. This section is derived from Eberl (2012). For more extensive analyses of the nature of suffering and our moral response to it, see Cassell (2004) and Green and Palpant (2014). 15. The relative percentages for these reasons have held consistently over the years since Oregon’s Death with Dignity Act was enacted in 1997, and hold similarly as well since Washington legalized PAS in 2009 (Emanuel et al., 2016, 85). 16. Note that, by “caregivers,” I am referring not only to health care professionals but also anyone who is present with the patient and provides care in a broadly-construed fashion, which includes family members, friends, pastoral ministers, non-professional volunteers, etc. 17. Although Nietzsche did not harbor much moral consideration for the “weak,” his ethic values active fortitude over passive acquiescence in one’s experience of suffering. 18. For an extensive list of the psychological, emotional, social, economic, and other stresses caregivers may experience, see Callahan (2015, 150–1). 19. To be clear, I am not claiming that there are any morally justifiable reasons for one to elect PAS, but that to contend such without also providing effective support to help ameliorate a patient’s suffering is analogous to a governmental “unfunded mandate” —that is, a command given without the support one needs to adhere to the command. Another way to conceptualize this claim is in terms of the Kantian “ought implies can” principle—viz., that one is bound by a moral duty only to the extent that one is capable of fulfilling said duty. Similarly, one cannot contend that a suffering patient ought to face suffering and impending death with fortitude without also providing the requisite support for the patient to act in a fortitudinous manner. 20. This recommendation could be construed as providing tacit support for PAS; however, it also refers to dying patients having their wishes respected concerning whether certain treatment options should be pursued, whether certain mechanical aids should be utilized or withheld/withdrawn, whether they wish to remain in the hospital or die at home with hospice care, etc. 21. Such practices may be secular or faith-based, involving practices such as mediating intra-familial conflict concerning care decisions, ameliorating moral distress health care practitioners may experience if care decisions are made with which they do not agree—whether involving over- or under-treatment—as well as providing spiritual support—ideally from either a hospital chaplain or a cleric from the patients’ own religious community with whom they have developed a close relationship. 22. Patients’ “communities” here and in the next bullet-point should be understood as one’s most immediate network of social relationships, augmented by support from the wider political community, as elucidated above. 23. Such “community-wide” discipline is best developed and practiced in the context of one’s most immediate network of social relationships, augmented by support from the wider political community, as elucidated above. 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