Christian Bioethics 24, no. 1 (April 2018):
"Physician-Assisted Suicide and Voluntary Euthanasia: Dying in a Post-Christian Age"

Elliot — "Institutionalizing Inequality: The Physical Criterion of Assisted Suicide"
David Elliot makes an important contribution to the assisted suicide debate in his article, "Institutionalizing Inequality: The Physical Criterion of Assisted Suicide." In Anglo-American legislation, the two measures generally used to restrict eligibility for assisted suicide are autonomy and physical criteria. While most assisted suicide arguments focus on autonomy, Elliot turns to the physical criterion to argue that it violates the equality of respect for all people and degrades a large class of people by determining that certain characteristics make life not worth living. The central problem, Elliot argues, is that the criterion degrades "tens of thousands of very sick and dying people" by judging their lives as not worthwhile. This creates a category of people for whom their physical conditions warrant assistance in death and a category of people for whom their lives are considered valuable and worth preserving despite physical conditions; the latter being offered suicide prevention instead of assistance in death.

One of the central problems with assisted suicide, Elliot notes, is that the state becomes the arbiter of moral status. In other words, the state takes an extreme form of paternalism when it makes judgments about what type of life is no longer worth living. This results in a societally-reinforced and institutionally-rooted degradation of certain groups of people. The equal moral status of a whole class of people is violated; this Elliot calls a "third party injury." Elliot notes that assisted suicide violates the central tenet of Western democracies to uphold the equal moral status and worth of all human beings before the law.

Next, Elliot notes that the secular argument he has made against assisted suicide is not only compatible with Christianity but also deepened by it. Turning to Aquinas, he shows that the degradation of persons through assisted suicide violates a theology of the imago dei where all human beings have inherent dignity. Theology deepens the understanding of who or what has been wronged in assisted suicide and shows that it injures our relationship with God.

Lastly, Elliot examines the viewpoint of those degraded by assisted suicide. Assisted suicide introduces a shift in decision-making for the group of people whose lives are deemed worthy of suicide, namely this group of people now has to choose not to die. With an aging population and the financial costs of caring for the elderly, assisted suicide shifts the burden of proof towards reasons for staying alive. Moreover, from a disability rights perspective, the physical criterion of assisted suicide implicates that certain disabilities may make life not worth living. Elliot asserts that the physical criterion of assisted suicide not only violates the equal moral status and respect that is owed to all in a democracy, but it also inflicts a degrading evaluative judgment on all people for whom the physical criterion is applicable. Elliot concludes by suggesting that in addition to the recovery of Christian practices and resources to address the problems of medicalized dying, we need to urgently devote our efforts to developing a theological virtue of hope that is rooted in the Resurrection.

Eberl — "I Am My Brother's Keeper: Communitarian Obligations to the Dying Person"
In his article, "I am my brother's keeper: Communitarian obligations to the dying person," Jason T. Eberl purposefully sidesteps the debate on whether PAS ought to be legal and instead focuses on communal duties towards the dying. Eberl claims that ethical indictments of PAS often end with arguments against allowing an individual to end his life, however, the positive communal duties to ameliorate the suffering of the dying are left unexamined. Eberl hopes that his argument will bolster the need for investment in palliative care amidst growing legalization and acceptance of PAS.

Before examining the communal duties towards the dying, Eberl briefly recounts the libertarian and communitarian arguments regarding PAS. Perhaps the most prominent argument in support of PAS is the libertarian idea that the voluntary, reasoned choices of autonomous individuals ought to be absolutely respected. In contrast, a communitarian argument against PAS holds that human beings are social beings who have duties and responsibilities towards their community. On this account, suicide is not merely a private act but one that has implications for the community. Following Aristotle and Aquinas, Eberl looks to the polis (i.e., the state) to draft legislation to prohibit PAS, since it is to this community that an individual has the negative obligation to not commit suicide. Importantly, there is a corresponding positive obligation for closely-delineated social communities to assist individuals to meet this negative obligation, since those close to an individual are best suited to care for him. As those caring for an individual also need assistance, then the wider social communities must assist the caretakers (e.g., paid time off from employers). Drawing from Callahan, Eberl notes that PAS requires two individuals to make this act possible and a complicit society to make the act acceptable. Perhaps most importantly, PAS "obviates communal obligations to suffering members," and Eberl then turns his focus to illuminating these communal obligations towards the dying members of society.

A common argument in support of PAS is that beneficence demands we alleviate the suffering of the dying, thus rendering PAS a compassionate discharge of duty towards the dying. However, Eberl contends that closely-delineated social communities have the positive obligation to alleviate the suffering of the dying. Concerning suffering, Eberl discusses some of the literature on the instrumental value of suffering: redemptive suffering, suffering as a source of repentance, and suffering as witness of moral character. Additionally, suffering can be a source of solidarity among patients and their caregivers. Eberl ends this section reiterating the importance of the wider communities supporting closely-delineated social communities since "co-suffering" in solidarity with dying patients necessitates the support of the whole community, even if only a few are directly caring for the dying individual.

After briefly recounting the Roman Catholic arguments against PAS, Eberl ends his article by exploring some practical suggestions for better communal care of dying. Given the sparse number of palliative care services nationwide, Eberl draws on some recent work by M. Therese Lysaught and Lydia Dugdale to sketch ways to "tame death" and incorporate the ars moriendi. Eberl concludes by highlighting a few programs that illustrate the communal care for the dying, including a program at Angola State Penitentiary in Louisiana where inmates serve as hospice volunteers for those who are dying within the prison while serving a life sentence. These practical guidelines and programs provide a concrete alternative to PAS, but there are potentially many more creative ways for the community to support the dying that need actualizing.

Synthesis
Both Elliot and Eberl make important contributions to the debate on PAS, albeit in different ways. Elliot's argument incorporates the disability rights perspective to show how current regulations of, and arguments in favor of, PAS actually denigrate a class of people by holding their lives to be unworthy of living. In Elliot's view, the arguments and legislature in favor of PAS fall flat without the "physical criterion" he critiques in his article. In the end, Elliot turns to Christianity and the theological virtue of hope rooted in the Resurrection to alleviate the suffering of the dying, who are so often made to believe that PAS is their best option.

In many ways, Eberl's article begins where Elliot's ends. Eberl purposefully sidesteps the entire debate on whether PAS should be available and instead emphasizes the positive obligations that social communities have to alleviate the suffering of the dying. In taking this approach, Eberl appeals to those on both sides of the PAS discussion and calls for more investment in palliative care programs. Like Elliot, Eberl draws from the Christian tradition and points to recent work on the ars moriendi to ultimately reframe the current debates around PAS. Another way these two articles complement one another is that Elliot focuses on the dying patients who, because of current regulations, are living lives deemed unworthy of living by the state, whereas Eberl turns his attention to the social communities that ought to support dying patients. Taken together, these two articles from the spring issue of Christian Bioethics bolster the Christian critique of PAS in creative ways and should appeal to a broad audience.

HCEUSA Literature Review by Jacob Harrison, PhD(c) and Christopher Ostertag, M.A.
*Jacob is a Ph.D. candidate and Christopher is a Ph.D. student in the Health Care Ethics program at Saint Louis University.

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