EUTHANASIA AND ASSISTED SUICIDE: A CHRISTIAN ETHICAL PERSPECTIVE

This article introduces and compares the contrasting views of two well-known the- ologians, Gilbert Meilaender and Harry Kuitert, on euthanasia and medically assisted suicide. Meilaender rejects euthanasia and medically assisted suicide, but accepts refusal of treatment, as long as it is not done with the intention to cause the death of the person involved. Kuitert favours euthanasia and medically assisted suicide, as well as the cessation of treatment with the intention to cause the death of the person involved in certain hopeless cases. The last section of the article attempts to for- mulate a Christian ethical view on euthanasia and assisted suicide in a dialogue with the two theologians.


INTRODUCTION
The ethical debate on euthanasia and assisted suicide in South Africa will certainly intensify in the future. This will primarily be a public debate on whether the legalisation of euthanasia and assisted suicide would be morally acceptable. Pressure is increasingly put upon international governments to initiate such legalisation. The government of the Netherlands was the first to succumb to public pressure and to lift the ban on euthanasia and assisted suicide under certain circumstances. 2 South Africa has not yet taken definite steps in legalising euthanasia and assisted suicide. However, a recent report by the Law Commission mentions legalisation as one of the options which the government will have to consider.
Churches and Christians are challenged to contribute to this public debate. In order to do so effectively, they will have to clarify their own Christian ethical views on euthanasia and assisted suicide, and reach greater consensus on how these two ways of putting an end to human life should be evaluated from a Christian ethical perspective. At present, the most divergent and even contradictory views are those of theologians, churches and church members.
In the Christian ethical debate on euthanasia and medically assisted suicide, the crucial factor is the intention to kill (in committing suicide and assisting in suicide, voluntary, involuntary and non-voluntary euthanasia). One can safely state that the majority of churches and theologians reject the intentional killing of human beings, although few theologians are of the opinion that intentional killing is morally justified in order to prevent a horrible death.
This article introduces and compares the views of two theologians who represent these majority and minority groups. Gilbert Meilaender (professor of Theological Ethics at Valparaiso University in Valparaiso, Indiana, USA) rejects euthanasia and medically assisted suicide, but accepts refusal of treatment, as long as it is not done with the intention to cause the death of the person involved. Harry Kuitert (emeritus professor of Ethics and of Introduction to Systematic Theology at the Theological Faculty, Free University, Amsterdam, The Netherlands) favours euthanasia and medically assisted suicide, as well as the cessation of treatment with the intention to cause the death of the person involved in certain hopeless cases. Kuitert served on several official advisory commissions of the Dutch government for the legalisation of euthanasia and assisted suicide.

THE CASE AGAINST EUTHANASIA AND MEDICALLY ASSISTED SUICIDE: THE VIEW OF GILBERT MEILAENDER
Meilaender is of the opinion that the application of ethical principles, such as respect for autonomy, beneficence, and justice, to particular issues in bioethics is never done in a vacuum. How we understand such principles, and how we understand the situations we encounter, will depend on background beliefs linked to moral reflection -beliefs about the meaning of human life, the significance of suffering and dying, and the ultimate context in which we understand our being and doing (Meilaender 1996:1). He points out that, as a result of their vision of the world, Christians have held that suicide -as a rational project, not as the irrational result of emotional illness -is morally wrong, as it contradicts our nature as creatures; it is an unwillingness to receive life from the hand of God without ever regarding it as simply "our" possession (Meilaender 1996:58). However, if my life is not simply my possession to dispose of as I see fit, as if the relation with God does not exist, the same is true of the lives of others. I have no authority to act as if I exercise lordship over another person's life and another person has no authority to make me lord over his life and death. The implication, according to Meilaender, is clear: Christians should not request or co-operate in either assisted suicide or euthanasia (Meilaender 1996:62).
Meilaender agrees with Paul Ramsey that Christians should articulate an ethic of "(only) caring for the dying" (Ramsey 1970: Chapter 3). Such an ethic would reject two opposite extremes: refusing to acknowledge death by continuing the struggle against it when that struggle is useless, or aiming to hasten the coming of death. Neither of these can be reckoned as caring for one of our fellow human beings; each is a form of abandonment. We should always try to care for the dying person, but we should only care.
Why might we be tempted to ask for or to offer euthanasia? There are at least two possible reasons: • The first is our commitment to autonomy or self-determination. On account of this commitment I may be tempted to believe that my life is my own to do with as I please, and that another person's life is her own to do with as she pleases. • The second is our desire to bring relief to those who suffer greatly. On account of this desire I may be tempted to assist someone in putting an end to her life if this appears to be the only way to avoid unbearable suffering.
Meilaender is of the opinion that self-determination as a criterion opens the door to euthanasia or assisted suicide not only for those who are suffering greatly, but also for those who find life meaningless. More importantly, the argument based on self-determination reflects a questionable individualist understanding of the human person that does not take into account her relation of dependence on God and other people. Moreover, for Christians, each person's life is a divine gift and trust, taken up into God's own eternal life in Jesus, to be guarded and respected in others and in oneself (Meilaender 1996:63-64).
We may also ask the following question: if the suffering of others makes such a powerful claim on us that we should kill them in order to terminate their suffering, why should we restrict such merciful relief only to those who are self-determining, who are competent to request it? Meilaender does not wish to deny that compassion for those who are suffering is central in the Christian worldview. The principle governing Christian compassion, however, is not to "minimise suffering", but to "maximise care". If our goal were only to minimise suffering, we could no doubt sometimes achieve it by eliminating sufferers. However, we refuse to understand suffering as part of human life that can have meaning or purpose. It is not that suffering in itself is a good thing. Suffering is an evil, but the God who in Jesus has not abandoned us in his suffering in Gethsemane and on the cross, can bring good for us as he did for Jesus (Meilaender 1996:65).
In caring for the dying we should not, on the one hand, choose death or aim at death. For that reason euthanasia and assisted suicide are not morally permitted. But we should, on the other hand, not act as if continued life is the only, or even the highest, good. It is not a good but a gift of God. Thus we should not continue the struggle against death when its time has come. According to Meilaender, "allowing to die" is permitted; killing is not (Meilaender 1996:69).
Meilaender is of the opinion that, although both the act of suicide and the refusal of treatment may result in my death, they are not necessarily morally equivalent. Although they could sometimes be morally equivalent -I could refuse treatment so that I will die -they need not be. If the aim is not to kill, but to avoid another evil, or simply to allow someone to die, refusing treatment is morally acceptable. The crucial distinction between an act's aim and its result also applies to the application of increasingly large doses of morphine to control pain in the last stages of terminal illness. One possible result of the treatment is that it may cause death more quickly by suppressing respiration. If, however, the intent is not to cause a quicker death, but to provide the best care possible in such difficult circumstances, such treatment for pain is morally acceptable (Meilaender 1996:69-71).
Meilaender distinguishes two guidelines that can help us decide when refusing treatment is not aimed at death (Meilaender 1996:71-75): • Treatment may be refused if it is useless. For the patient who is irrevocably dying, few if any treatments can be useful. Continued attempts to cure such a patient only impose needlessly and may well get in the way of the effort to care for this person as best we can. • Treatments that are useful may sometimes be excessively burdensome. We may rightly refuse even useful treatment that would prolong our life for a significant period of time if it really does carry with it significant burdens. Cessation of treatment should never occur on account of the burdens of life -that would be unacceptable from a Christian perspective -but only on account of the burdens of treatment.

THE CASE FOR EUTHANASIA AND MEDICALLY ASSISTED SUICIDE: THE VIEW OF HARRY KUITERT
Unlike Meilaender, Kuitert starts not with a discussion of the Christian worldview and its implications for an ethical stance on euthanasia and assisted suicide, but with a religiously neutral ethical discussion of these issues. He devotes attention to -in his view largely motivational -contribution of the Christian worldview to the euthanasia debate only in the penultimate section of his book (Chapters 15 to 19) (Kuitert 1993:117-155). For Kuitert, the right context for the ethical discussion on euthanasia --defined by him as the deliberate termination of someone's life at his/her own request by someone else -is that the medical profession should render assistance in dying. It is part and parcel of the professional and moral duty of the physician to assist his/her patient in dying. A good physician, according to Kuitert, is one who sees to it that his/her patient does not come to a bitter end (Kuitert 1993:17-23).
The negative aspect of medical progress is that nowadays dying is often a bitter experience, as a result of the fact that there are only three to four rather wretched exits to life. The moral duty of the physician to assist his/ her patients in dying therefore entails -in Kuitert's opinion -the moral duty to grant an increasing number of patients their request for euthanasia or assisted suicide if, in the professional opinion of the physician, there is no hope from a medical perspective. Euthanasia (or assisted suicide) is morally acceptable not only in the case of unbearable physical suffering but also in the case of terminally ill patients who prefer to die in dignity before their bodies degenerate and they are exposed to excruciating pain (Kuitert 1993:27-34).
To justify his view Kuitert discusses the universally recognised command "Thou shalt not kill". This command should not be interpreted as an absolute prohibition of all killing, but as a prohibition of unjustified killing. The answer to the question: "Why may one person not kill another person?" is not as simple as it seems. The reference to the sacredness of life is too abstract. It is better to take as point of departure every person's inalienable right to life. This right is, however, not impaired in the case of euthanasia or assisted suicide, because it is administered at the explicit request of the patient (Kuitert 1993:35-40).
Does the terminally ill patient have the moral right to will her own death and request someone else to assist her in terminating her life? To jus-tify this moral right Kuitert appeals to the right to exercise self-determination. I have the right not to let others decide on how I should live or die, but to decide for myself, in accordance with my own moral and religious beliefs. This includes the right to indicate that my time for dying has come. This does not imply that a physician has the juridical duty to help me terminate my life. The physician does, however, have the moral duty to grant me my request for a mild and quick death as alternative for a bitter end in situations where I am unable to help myself (Kuitert 1993:72-80).
Kuitert takes to task two attempts to avoid confrontation with the moral problem of the termination of life: he introduces the terms "indirect euthanasia" and "passive euthanasia". He does not find "indirect euthanasia" a useful term, because the increasing dosage of morphine is intended either to terminate life -in which case the addition of "indirect" is unnecessary and misleading -or not to terminate life -in which case the word "euthanasia" is not applicable and its use is also misleading (Kuitert 1993:41-47). In criticising the distinction "active and passive euthanasia" Kuitert has no intention to deny that, for the most part, there is a crucial difference between "causing to die" and "letting die". What is problematic in his opinion is that physicians use this distinction to defend a specific strategy: by "letting die" one can avoid "causing to die". To intentionally let someone die is, in his opinion, causing her to die. The result and the intention are similar: the patient dies and the moral accountability is similar (Kuitert 1993:48-54).
Kuitert realises that sometimes "passive euthanasia" merely implies withdrawal of treatment or the decision not to commence with treatment. In most cases, such withdrawal of treatment is no life-terminating action and therefore, in his opinion, it is not part of the euthanasia debate. If a patient requests such a withdrawal of treatment, the physician has no moral right to refuse. When a patient is not in the position to give consent, treatment should be withdrawn if such treatment does not in any way contribute to her well-being (Kuitert 1993:55-62). There are, however, cases where patients are not in a position to request withdrawal of treatment, and where such a withdrawal directly contributes to the death of patients. In the case of patients in a Persistent Vegetative State and some severely handicapped neonates, the withdrawal of intravenous feeding and other basic medical procedures inevitably and quickly results in death. Such termination of life that does not meet the minimum criteria of human life is, in Kuitert's opinion, morally justified, because the well-being of a human person is not served by continuous medical treatment (Kuitert 1993:95-103).
Once he has dealt with the ethical issues surrounding euthanasia, assisted suicide and withdrawal of treatment, Kuitert turns to the question whether there are elements in the Christian religion that have or should have an influence on the ethical views of Christians on these issues. His opinion is obvious: this is not the case. He differs from theologians who maintain that the Christian belief that life is a gift of God the Creator implies that self-determination resulting in euthanasia is morally unacceptable to Christians. Although such a belief contributes to a positive attitude to life, it does not contravene our God-given responsibility to decide for ourselves when the termination of human life is the lesser of two evils (Kuitert 1993:119-127). Kuitert also differs from theologians who believe that we should accept the suffering which God in his providence thrusts upon us. God's providence does not eliminate our responsibility to combat suffering, even if the only way to overcome unbearable suffering is by means of euthanasia (Kuitert 1993:134-139).

AN APPRAISAL
It is not possible to provide in this article a comprehensive and exhaustive analysis and evaluation of the views of Meilaender and Kuitert on assisted suicide and euthanasia. An attempt is rather made to find pointers to an adequate Christian ethical view by comparing and weighing some of their arguments.

4.1
Although both Meilaender and Kuitert regard themselves as Christian ethicists, it is obvious that their approaches to Christian Ethics differ radically. One can characterise Kuitert's approach as modernist. He believes that the content of the moral law is self-evident and can be known by reason independently of Christian religious beliefs. Christian religion only provides extra motivation for adhering to the moral principles shared by Christians and non-Christians. 3 Meilaender shares the post-modernist rejection of a moral law that is given and known independently of specific moral and religious traditions. Not only the motivation of Christians for doing the morally right thing, but also their understanding and application of moral values are, in his opinion, influenced by their religious beliefs and have a distinctive Christian flavour.

4.2
It is evident that Kuitert is merely interested in ethical reflection that can inform public policy. His approach reflects the general tendency in bioethical reflection to focus more and more on public policy -which in our society inevitably means a minimal, lowest-common-denominator ethic capable, it is thought, of securing public consensus (Meilaender 1996:x). There is nothing wrong with such an endeavour. It is understandable that Kuitert, who is actively involved in official commissions advising the government of the Netherlands on public policy regarding assisted suicide and euthanasia, would be primarily interested in the public debate. He does not, however, seem to recognise that there is a legitimate place for a thicker, maximally and specifically Christian ethic in the private and professional lives of Christians. 4 In fact, it seems as if he -in my opinion unjustifiably -is satisfied even in the private and professional spheres with a very thin, liberal morality (primarily based on the moral principle of autonomy).

4.3
One may ask whether the wider acceptance today of voluntary and nonvountary euthanasia and assisted suicide in Western countries such as the Netherlands can only be attributed to the fact that the prolongation of life as a result of modern medicine is not experienced purely as a blessing. It can, most probably, also be attributed to the prevalence of values such as autonomy, utility, productivity and cost-effectiveness that have their origin in specifically Western worldviews. From the perspective of these prevalent values, it makes no sense at all to prolong the life of someone in a Persistent Vegetative State. Such a person cannot make autonomous decisions and cannot in any way productively contribute to society. He needs continuous and intensive medical care, and puts a strain on the medical and financial resources of the state. However, the same is true of many elderly people suffering from dementia or Alzheimer, as well as many severely handicapped people. Where do we draw the line with regard to euthanasia if the prevalent functionalist values of our day are taken as point of departure?

4.4
Kuitert rightly emphasises that Christians should realise that modern technology -including medical technology -has expanded the scope of our moral responsibility immensely. We have, inter alia, to take responsibility for the elimination of the negative consequences of the prolongation of life as a result of the application of medical technology -as far as possible. Kuitert rightly states that Christian beliefs about life as a gift of God and the providence of God do not contradict our responsibility in this regard. Just as there are moral limits to our application of modern technology, there are, however, also moral limits -and not only physical limits as Kuitert seems to imply -to our attempts to eliminate the negative results of modern medical technology. Kuitert does not seem to adequately recognise these moral limits. He seemingly only takes self-determination and the duty to eliminate suffering into account as decisive moral principles. As Meilaender rightly points out: none of these moral principles on their own can prevent an increase in the number of indications for voluntary and nonvoluntary euthanasia and assisted suicide.
Kuitert pays some attention to the command "Thou shalt not kill". He rightly points out that this command is not absolute, because there are situations in which the killing of a human being is the lesser of two evils. He does not, however, adequately take into account the very strong presumption against the killing of human beings, in particular innocent human beings, in the history of Christian theology. Neither does he recognise that this strong presumption is the result of specific Christian beliefs. One such belief is that all human beings are created in the image of God and are therefore bestowed with a special dignity. Another is that life is a gift of God, which consists, among others, in being in a relationship of trust in and dependence on God. As a result of this strong presumption against the killing of an innocent human being, Christians should resist any attempt to classify voluntary and non-voluntary euthanasia and assisted suicide as morally justified killing.

4.5
Christians believe that personhood does not depend on the presence of certain characteristics such as consciousness, but is bestowed on every human being by God and should as such be recognised by fellow human beings. 5 Not even the most severely handicapped neonates and permanently coma-5 See for a discussion of when the status of person apply to a human being also Smedes (1971:99-156).
tose patients lose their status as persons. The intentional killing of them is therefore far more problematic, from a Christian point of view, than Kuitert would want to admit. We, of course, have the moral responsibility to eliminate the negative results of the prolongation of human life as a result of the application of medical technology. The command "Thou shalt not kill" should, however, be taken seriously as a moral limit to our responsibility in this regard. From a Christian ethical perspective, it is not only true that the sixth commandment applies as much to severely handicapped neonates and permanently comatose patients as to other persons. Both the Old and the New Testaments emphasise the obligation of believers to provide special care to those in society who are weak. Believers are reminded of this obligation, as they are always tempted not to recognise the equal status of the weak and to neglect their rights and even to actively discriminate against them. This temptation is very real in the case of severely handicapped neonates and permanently comatose patients. Not to recognise their equal right to life is the temptation par excellence. This temptation can only be countered by recognising our special obligation to respect the right to life of people with no or very little consciousness.

4.6
Christians believe that sin is a reality. They would therefore consider the very real possibility that less noble motives play a role in non-voluntary euthanasia in particular. They would also be aware of subtle shifts in the motivation for non-voluntary euthanasia from legitimate considerations in respect of further treatment being useless to illegitimate considerations in respect of the life of the patient being useless. Even in the case of voluntary euthanasia wrong motives can play a role if a patient submits to real or perceived pressure by family members or other people to terminate her life. There is also the possibility of misunderstanding. Most requests by terminally ill persons for an overdose of morphine are probably not so much for euthanasia, but for better assistance in dying: more effective administering of painkilling remedies and especially better pastoral support. 6 All these considerations strengthen the Christian presumption against euthanasia and assisted suicide.

4.7
In my opinion, Christians should distinguish between the administering of voluntary, involuntary and non-voluntary euthanasia and assisted suicide where the intention is to terminate life, which is morally unacceptable, and the withdrawal or refusal of medical treatment where the intention is only to stop treatment that does not add to the well-being of the patient, which is morally acceptable. It is true that in many instances the withdrawal of treatment will most probably result in the death of the patients involved. If a terminally ill cancer patient, for example, contracts pneumonia, she will most probably die if no antibiotics are administered. It would, however, not be appropriate to accuse either the medical doctor, who refused to give antibiotics, of killing, or the patient, who requested the withdrawal of treatment, of suicide. No one is responsible for the death of the patient, because the real cause of her death is her illness -the combination of severe pneumonia and terminal cancer. It would also be inappropriate to say that the intention of the persons involved in the decision to withdraw treatment is to kill the patient involved. Their intention is rather to put an end to useless and excessively burdensome medical treatment and to allow the patient to die.

4.8
Does this mean that a Christian should never agree to the administering of euthanasia? I do not think so. There are exceptional and extreme circumstances in which euthanasia may be the lesser of two evils. Years ago I saw a film on a terminally ill cancer patient, living in a boarding house. A nurse, who, among others, administered morphine injections to relieve his pain, visited him daily. He often pleaded that she should administer an overdose of morphine that would kill him and relieve him of his misery, once and for all. She consistently refused. On a particular day, however, a fire broke out in the boarding house while she did her house call. Realising that she would be unable to carry him to safety in time, she decided to administer the overdose of morphine to spare him a dreadful death by fire. In her eyes administering the overdose of morphine was in that extreme and exceptional situation the lesser of the two evils. In my opinion it would be better for any outsider not to morally condemn her conduct. There are some complex situations in life where only those who are directly involved are in a position to responsibly decide which of the available options would bring about the least evil. For them not to do the lesser of the evils could mean to shy away from the "free responsibility" they are called to by God. 7

CONCLUSION
Assisted suicide and euthanasia are unacceptable from the perspective of "thick" Christian morality, although we have to make provision for some extreme and exceptional situations in which it could be the lesser of two evils. Christians will, however, have to distinguish between the internal ethical discourse with fellow Christians and their personal Christian stance on euthanasia and assisted suicide, on the one hand, and the external, public discourse with people from different religions and worldviews on public policy, on the other hand. This article only paid attention to the internal, distinctly Christian discourse. In the public policy debate Christians will have to make room for other viewpoints, seek consensus and sometimes have to accept compromises. Even in the public policy debate, however, Christians should always, in my opinion, argue for strong legal safeguards against the intentional killing of innocent people, although legal room should be made for exceptional cases such as the one discussed above.