BIOETHICS AT THE END OF LIFE

DETERMINING DEATH
In the Catholic tradition, death is conceptualized as the separation of the soul from the body. A
person ceases to be alive when the principle of life is lost. In either case, the biggest problem is
that we do not know when a soul leaves the body, that is, we cannot observe the precise
moment of death. John Paul II taught:
 The death of the person, understood in this primary sense (i.e., the separation of the
soul from the body), is an event which no scientific technique or empirical method can
identify directly. Yet human experience shows that once death occurs certain biological
signs inevitably follows, which medicine has learnt to recognize with increasing
precision. In this sense, the criteria for ascertaining death used by medicine today
should not be understood as the technical-scientific determination of the exact moment
of a person’s death, but as a scientifically secure means of identifying the biological
signs that a person has indeed died. (Address to the 18 th International Congress of the
Transplantation Society)
 Why does death exist? What is its meaning? Christian faith affirms that there is a
mysterious link between death and moral disorder or sin. Yet at the same time, faith
imbues death with a positive meaning because it has the resurrection at its
horizon. ..such is death seen through the eyes of faith. It is not so much an end of living
as an entry into new life, a life without end. If we freely accept the love which God offer
us, we will have a new birth in joy and in light, a new dies natalis. (Determining the
Moment when Death Occurs, 4)
 Scientists, analysts and scholars must pursue their research and studies in order to
determine as precisely as possible the exact moment and the indisputable sign of death.
For, once such determination has been arrived at, then the apparent conflict between
the duty to respect the life of one person and the duty to effect a cure or even save the
life of another, disappears. (Determining the Moment when Death Occurs, 6)
Description of a Dead Body
To call a body dead is to say that it is in a state of widespread nonfunction – including a loss of
neurological functions (particularly consciousness and brain stem reflexes), circulation and
respiration – and this state naturally becomes permanent within minutes.
Neurological Criteria
Brain death – refers to the irreversible loss of all functions of the entire brain, including the
brain stem.
The three essential findings in brain death are coma, absence of brain stem reflexes and apnea.

1
  Coma: requires ‘eyes-closed coma’ and unresponsiveness to painful stimuli and should
be established as irreversible which excludes the states that can mimic brain death such
as locked-in syndrome, hypothermia, and drug intoxication.
 Absence of brain stem reflexes: no pupil response to bright light, no ocular movement,
no corneal reflexes and no gag or cough reflexes
 Apnea: no respiratory effort even when the patient is taken off the ventilator and
carbon dioxide levels are allowed to drop into a range that should stimulate respiratory
movements
It is interesting to note that no one has ever recovered from brain death when it has been
correctly determined. Far from assuming that human beings are distinct from their bodies,
defenders of the neurological criteria for determining death assert that the connection
between mind and body is so tight that a mind cannot animate a body with a dead brain.
Circulatory-Respiratory Criteria
Circulatory and respiratory criteria have again become controversial as they are applied in the
context of donation after cardiac death. A number of commentators have questioned whether
the patients have irreversibly lost circulatory-respiratory functions when death is declared only
two to five minutes following apnea and a loss of circulation.
If one focuses on a loss of brain function rather than structural damage; then the brain has
indeed lost all functions when loss of circulation has been verified for two to five minutes. In
establishing an irreversible loss of circulatory-respiratory functions, one does not need to
consider the possibilities of modern resuscitative medicine but the parameters of spontaneous
recovery set by nature.
The Uniform Determination of Death Act states that: An individual who has sustained either (1)
irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all
functions of the entire brain, including the brain stem, is dead. A determination of death must
be made in accordance with accepted medical standards. Moreover, the only person who is
competent to determine death on a person is the physician or the medical competent authority
and once brain dead is determined, which is the total brain, the heart also stops, and no
spontaneous respiration can be recognized. That is why, determination of death would include
the irreversible loss of all functions of the entire brain, excluding cellular-level and hormonal
regulatory functions; irreversible loss of consciousness and irreversible loss of circulatory
functions (Veatch, 126). Thus, we can say that the person is really dead when all bodily
functions ceases.
Finally, in the determination of death, it is important to recall that we can obtain only moral
certitude, not absolute certitude.
The Catholic teachings would tell us that it is important to determine the moment of death
since human life is sacred, and that God did not make death but instead gives life. "God did not

2
make death, and he does not delight in the death of the living. For he has created all things that
they might exist ... God created man for incorruption and made him in the image of his own
eternity, but through the devil's envy death entered the world, and those who belong to his
party experience it" (Wis 1:13-14; 2:23-24).
 The Gospel of life, proclaimed in the beginning when man was created in the image of
God for a destiny of full and perfect life (cf. Gen 2:7; Wis 9:2-3), is contradicted by the
painful experience of death which enters the world and casts its shadow of
meaninglessness over man's entire existence. Death came into the world as a result of
the devil's envy (cf. Gen 3:1,4-5) and the sin of our first parents (cf. Gen 2:17, 3:17-19).
And death entered it in a violent way, through the killing of Abel by his brother Cain:
"And when they were in the field, Cain rose up against his brother Abel, and killed him"
(Gen 4:8). (EV, 7)
However, on another perspective, the Church defines death as that which occurs when the
spiritual principle which ensures the unity of the individual can no longer exercise its functions
in and upon the organism, whose elements, left to themselves, disintegrate. (Boyle et al, 119)
 It is often awaited even as a liberation from the suffering of this life. At the same time, it
is not possible to ignore the fact that it constitutes as it were a definitive summing-up of
the destructive work both in the bodily organism and in the psyche. But death primarily
involves the dissolution of the entire psychophysical personality of man. The soul
survives and subsists separated from the body, while the body is subjected to gradual
decomposition according to the words of the Lord God, pronounced after the sin
committed by man at the beginning of his earthly history: "You are dust and to dust you
shall return". (SD, 15)
 In this regard, it is helpful to recall that the death of the person is a single event,
consisting in the total disintegration of that unitary and integrated whole that is the
personal self. It results from the separation of the life-principle (or soul) from the
corporal reality of the person. The death of the person, understood in this primary
sense, is an event which no scientific technique or empirical method can identify
directly…Yet human experience shows that once death occurs certain biological signs
inevitably follow, which medicine has learnt to recognize with increasing precision. In
this sense, the "criteria" for ascertaining death used by medicine today should not be
understood as the technical-scientific determination of the exact moment of a person's
death, but as a scientifically secure means of identifying the biological signs that a
person has indeed died. (Address of the Holy Father John Paul II to the 18 th International
Congress of the Transplantation Society, 4)
Finally, the determination of death should be made by the physician or competent medical
authority in accordance with responsible and commonly accepted scientific criteria. (ERDCHCS,
62)

3
Source: DuBois, James. Determining Death in Catholic Health Care Ethics: A Manual for
Practitioners. Philadelphia, PA: The National Catholic Bioethics Center. 2009.
Veatch, Robert and Lainie Ross. Transplantation Ethics. 2 nd ed. Washington D.C.: Georgetown
University Press. 2015.
John Paul II. Evangelium Vitae
John Paul II. Address to the 18th International Congress of the Transplantation Society
John Paul II. Determining the Moment when Death Occurs
USCCB. Ethical and Religious Directives for Catholic Health Care Services

PHYSICIAN-ASSISTED SUICIDE AND EUTHANASIA

At the other end of life's spectrum, men and women find themselves facing the mystery of
death. Today, as a result of advances in medicine and in a cultural context frequently closed to
the transcendent, the experience of dying is marked by new features. When the prevailing
tendency is to value life only to the extent that it brings pleasure and well-being, suffering
seems like an unbearable setback, something from which one must be freed at all costs. Death
is considered "senseless" if it suddenly interrupts a life still open to a future of new and
interesting experiences. But it becomes a "rightful liberation" once life is held to be no longer
meaningful because it is filled with pain and inexorably doomed to even greater suffering. (EV,
64)
In this context the temptation grows to have recourse to euthanasia, that is, to take control of
death and bring it about before its time, "gently" ending one's own life or the life of others. In
reality, what might seem logical and humane, when looked at more closely is seen to be
senseless and inhumane. Here we are faced with one of the more alarming symptoms of the
"culture of death", which is advancing above all in prosperous societies, 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.
(EV, 64)
Physician-assisted suicide and euthanasia are two forms of unjust killings. In the first, the
physician assists in the patient’s own act of self-destruction; in the second, someone directly
kills the patient either with or without consent.
 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
4
 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. (1980 Declaration on Euthanasia,
3)
Advocates of euthanasia hold that certain lives are not worth living – or, less delicately put, that
some people are better off dead. These people typically include not only those in the end
stages of terminal illness but also those in persistent vegetative state, the aged, the mentally
incompetent, and children who suffer serious fetal anomalies.
However, we should identify first the types of euthanasia. Moral theology qualifies what we
have described as direct or active euthanasia, i.e., intentional killing of a tormented, incurable
patient by lethal agents or means. By indirect or passive euthanasia one understands the relief
of sufferings by means of sedatives and narcotics with a shortening of life as a side effect.
Passive euthanasia is the lightening of death through omission or discontinuation of life-
prolonging measures. It is interesting to note, however, that the Pontifical Council Cor unum
merits approval that the term ‘euthanasia’ be reserved to its direct active form. So, the use of
the term ‘euthanasia’ signifies the active type of euthanasia which is the intentional killing of
innocent human being. (Peschke, 328)
 The word Euthanasia is used in a more particular sense to mean "mercy killing," for the
purpose of putting an end to extreme suffering, or having abnormal babies, the mentally
ill or the incurably sick from the prolongation, perhaps for many years of a miserable
life, which could impose too heavy a burden on their families or on society. By
euthanasia is understood an action or an omission which of itself or by intention causes
death, in order that all suffering may in this way be eliminated.
 Etymologically speaking, in ancient times Euthanasia meant an easy death without
severe suffering. Today one no longer thinks of this original meaning of the word, but
rather of some intervention of medicine whereby the suffering of sickness or of the final
agony are reduced, sometimes also with the danger of suppressing life prematurely.
Ultimately, the word Euthanasia is used in a more particular sense to mean "mercy
killing," for the purpose of putting an end to extreme suffering, or having abnormal
babies, the mentally ill or the incurably sick from the prolongation, perhaps for many
years of a miserable life, which could impose too heavy a burden on their families or on
society. (CDF Declaration on Euthanasia)
 By euthanasia is understood an action or an omission which of itself or by intention
causes death, in order that all suffering may in this way be eliminated. Euthanasia's
terms of reference, therefore, are to be found in the intention of the will and in the
methods used. (CDF Declaration on Euthanasia)

5
  Pope John Paul II says in Evangelium Vitae: “euthanasia in the strict sense is understood
to be an action or omission which of itself and by intention causes death, with the
purpose of eliminating all suffering. Euthanasia's terms of reference, therefore, are to be
found in the intention of the will and in the methods used.” (EV, 65)
 Euthanasia should be distinguished from the refusal of ‘aggressive medical treatment’ in
which medical procedures are employed that no longer correspond to reasonable
prospects for continued life in the patient. Furthermore, “to forgo extraordinary or
disproportionate means is not the equivalent of suicide or euthanasia; it rather
expresses acceptance of the human condition in the face of death (EV, 65).”
 The Church is convinced of the necessity to reaffirm as definitive teaching that
euthanasia is a crime against human life because, in this act, one chooses directly to
cause the death of another innocent human being…The moral evaluation of euthanasia,
and its consequences does not depend on a balance of principles that the situation and
the pain of the patient could, according to some, justify the termination of the sick
person. Values of life, autonomy, and decision-making ability are not on the same level
as the quality of life as such…Euthanasia, therefore, is an intrinsically evil act, in every
situation or circumstance. (CDF Samaritanus Bonus)
Four general principles governing “due proportion in the use of remedies.”
 If other alternatives are not available, one may make use of the most advanced, even if
still experimental medical procedures.
 One may also refuse or cease to use extraordinary means if the benefits they provide
fall short of expectations.
 One may make do with the ordinary means available and refuse all extraordinary
means.
 When death is imminent one may refuse forms of treatment that would only secure a
precarious and burdensome prolongation of life.
Catholic health care institutions may never condone or participate in euthanasia or assisted
suicide in any way. Dying patients who request euthanasia should receive loving care,
psychological and spiritual support, and appropriate remedies for pain and other symptoms so
that they can live with dignity until the time of natural death. (USCCB Ethical and Religious
Directives for Catholic Health Care Services)
 John Paul II says in Evangelium Vitae: I confirm that euthanasia is a grave violation of the
law of God, since it is the deliberate and morally unacceptable killing of a human
person. This doctrine is based upon the natural law and upon the written word of God,
is transmitted by the Church's Tradition and taught by the ordinary and universal
Magisterium. Depending on the circumstances, this practice involves the malice proper
to suicide or murder. (EV, 65)
 The choice of euthanasia becomes more serious when it takes the form of a murder
committed by others on a person who has in no way requested it and who has never
6
 consented to it. The height of arbitrariness and injustice is reached when certain people,
such as physicians or legislators, arrogate to themselves the power to decide who ought
to live and who ought to die… God alone has the power over life and death: "It is I who
bring both death and life" (Dt 32:39; cf. 2 Kg 5:7; 1 Sam 2:6). But he only exercises this
power in accordance with a plan of wisdom and love. When man usurps this power,
being enslaved by a foolish and selfish way of thinking, he inevitably uses it for injustice
and death. (EV, 66)
 Whatever its motives and means, direct euthanasia consists in putting an end to the
lives of handicapped, sick, or dying persons. It is morally unacceptable. Thus an act or
omission which, of itself or by intention, causes death in order to eliminate suffering
constitutes a murder gravely contrary to the dignity of the human person and to the
respect due to the living God, his Creator. The error of judgment into which one can fall
in good faith does not change the nature of this murderous act, which must always be
forbidden and excluded. (CCC 2277)
 When a request for euthanasia rises from anguish and despair, “although in these cases
the guilt of the individual may be reduced, or completely absent, nevertheless the error
of judgment into which the conscience falls, perhaps in good faith, does not change the
nature of this act of killing, which will always be in itself something to be rejected”. The
same applies to assisted suicide. Such actions are never a real service to the patient, but
a help to die. (CDF Samaritanus Bonus)
 Euthanasia and assisted suicide are always the wrong choice: “the medical personnel
and the other health care workers – faithful to the task ‘always to be at the service of
life and to assist it up until the very end’ – cannot give themselves to any euthanistic
practice, neither at the request of the interested party, and much less that of the family.
In fact, since there is no right to dispose of one’s life arbitrarily, no health care worker
can be compelled to execute a non-existent right”. This is why euthanasia and assisted
suicide are a defeat for those who theorize about them, who decide upon them, or who
practice them. (CDF Samaritanus Bonus)

Source: Furton, Edward. Physician-Assisted Suicide and Euthanasia in Catholic Health Care
Ethics: A Manual for Practitioners. Philadelphia, PA: The National Catholic Bioethics Center.
2009.
Peschke, Karl. Christian Ethics: Moral Theology in Light of Vatican II Volume 2 Special Moral
Theology (Newly Revised Edition). Eugene, OR: Wipf and Stock Publishers. 2010.
Sacred Congregation for The Doctrine of The Faith. Declaration on Euthanasia. May 5, 1980.
Rome.
John Paul II. Evangelium Vitae
Catechism of the Catholic Church

7
Congregation for the Doctrine of the Faith. Samaritanus Bonus: on the care of persons in the
critical and terminal phases of life.
PALLIATIVE CARE, PAIN MANAGEMENT AND HUMAN SUFFERING
Illness and suffering have always been among the gravest problems confronted in human life. In
illness, man experiences his powerlessness, his limitations, and his finitude. Every illness can
make us glimpse death. It can lead to anguish, self-absorption, sometimes even despair and
revolt against God. It can also make a person more mature, helping him discern in his life what
is not essential so that he can turn toward that which is. Very often illness provokes a search for
God and a return to him. (Catechism of the Catholic Church 1500-1501)

Palliative Care
Palliative care is any form of medical care or medical treatment that concentrates on reducing
the severity of disease symptoms rather than providing a cure. It also involves a
comprehensive plan for serving the needs of persons who are ill, who are usually living with a
terminal or chronic diagnosis for which care can be provided but for which a cure is not
anticipated.
 The task of medicine is to care even when it cannot cure. Physicians and their patients
must evaluate the use of the technology at their disposal. Reflection on the innate
dignity of human life in all its dimensions and on the purpose of medical care is
indispensable for formulating a true moral judgment about the use of technology to
maintain life. The use of life-sustaining technology is judged in light of the Christian
meaning of life, suffering, and death. In this way two extremes are avoided: on the one
hand, an insistence on useless or burdensome technology even when a patient may
legitimately wish to forgo it and, on the other hand, the withdrawal of technology with
the intention of causing death. (USCCB Ethical and Religious Directives for Catholic
Health Care Services)
 Continuity of care is part of the enduring responsibility to appreciate the needs of the
sick person: care needs, pain relief, and affective and spiritual needs. As demonstrated
by vast clinical experience, palliative medicine constitutes a precious and crucial
instrument in the care of patients during the most painful, agonizing, chronic and
terminal stages of illness. Palliative care is an authentic expression of the human and
Christian activity of providing care, the tangible symbol of the compassionate
“remaining” at the side of the suffering person. Its goal is “to alleviate suffering in the
final stages of illness and at the same time to ensure the patient appropriate human
accompaniment” improving quality of life and overall well-being as much as possible
and in a dignified manner. Experience teaches us that the employment of palliative care
reduces considerably the number of persons who request euthanasia. To this end, a
resolute commitment is desirable to extend palliative treatments to those who need
8
 them, within the limits of what is fiscally possible, and to assist them in the terminal
stages of life, but as an integrated approach to the care of existing chronic or
degenerative pathologies involving a complex prognosis that is unfavorable and painful
for the patient and family. (CDF Samaritanus Bonus)
 Catholic health care institutions offering care to persons in danger of death from illness,
accident, advanced age, or similar condition should provide them with appropriate
opportunities to prepare for death. Persons in danger of death should be provided with
whatever information is necessary to help them understand their condition and have
the opportunity to discuss their condition with their family members and care providers.
They should also be offered the appropriate medical information that would make it
possible to address the morally legitimate choices available to them. They should be
provided the spiritual support as well as the opportunity to receive the sacraments in
order to prepare well for death. (ERDCHCS, 55)

Pain Management
With advances in medicine, pain management is readily achieved. Pope Pius XII affirmed that it
is licit to relieve pain by narcotics, even when the result is decreased in consciousness and a
shortening of life.
 The use of painkillers to alleviate the sufferings of the dying, even at the risk of
shortening their days, can be morally in conformity with human dignity if death is not
willed as either an end or a means, but only foreseen and tolerated as inevitable.
Palliative care is a special form of disinterested charity. As such it should be encouraged.
(CCC 2279)
 In modern medicine, increased attention is being given to what are called "methods of
palliative care", which seek to make suffering more bearable in the final stages of illness
and to ensure that the patient is supported and accompanied in his or her ordeal.
Among the questions which arise in this context is that of the licitness of using various
types of painkillers and sedatives for relieving the patient's pain when this involves the
risk of shortening life. While praise may be due to the person who voluntarily accepts
suffering by forgoing treatment with painkillers in order to remain fully lucid and, if a
believer, to share consciously in the Lord's Passion, such "heroic" behavior cannot be
considered the duty of everyone. Pius XII affirmed that it is licit to relieve pain by
narcotics, even when the result is decreased consciousness and a shortening of life, "if
no other means exist, and if, in the given circumstances, this does not prevent the
carrying out of other religious and moral duties”. In such a case, death is not willed or
sought, even though for reasonable motives one runs the risk of it: there is simply a
desire to ease pain effectively by using the analgesics which medicine provides. All the
same, "it is not right to deprive the dying person of consciousness without a serious

9
 reason": as they approach death people ought to be able to satisfy their moral and
family duties, and above all they ought to be able to prepare in a fully conscious way for
their definitive meeting with God. (EV, 65)
 But the intensive use of painkillers is not without difficulties, because the phenomenon
of habituation generally makes it necessary to increase their dosage in order to maintain
their efficacy. At this point it is fitting to recall a declaration by Pius XII, which retains its
full force; in answer to a group of doctors who had put the question: "Is the suppression
of pain and consciousness by the use of narcotics ... permitted by religion and morality
to the doctor and the patient (even at the approach of death and if one foresees that
the use of narcotics will shorten life)?" the Pope said: "If no other means exist, and if, in
the given circumstances, this does not prevent the carrying out of other religious and
moral duties: Yes." In this case, of course, death is in no way intended or sought, even if
the risk of it is reasonably taken; the intention is simply to relieve pain effectively, using
for this purpose painkillers available to medicine. However, painkillers that cause
unconsciousness need special consideration. For a person not only has to be able to
satisfy his or her moral duties and family obligations; he or she also has to prepare
himself or herself with full consciousness for meeting Christ. Thus Pius XII warns: "It is
not right to deprive the dying person of consciousness without a serious reason." (CDF
Declaration on Euthanasia)
 Patients should be kept as free of pain as possible so that they may die comfortably and
with dignity, and in the place where they wish to die. Since a person has the right to
prepare for his or her death while fully conscious, he or she should not be deprived of
consciousness without a compelling reason. Medicines capable of alleviating or
suppressing pain may be given to a dying person, even if this therapy may indirectly
shorten the person’s life so long as the intent is not to hasten death. (USCCB Ethical and
Religious Directives for Catholic Health Care Services)

Suffering
Patients experiencing suffering that cannot be alleviated should be helped to appreciate the
Christian understanding of redemptive suffering. There is meaning in suffering because through
it we share in Christ’s suffering. Suffering especially suffering during the ;ast moments of life,
has a special place in God’s saving plan; it is in fact a sharing in Christ’s Passion and a union with
the redeeming sacrifice which he offered in obedience to the Father’s will.
 John Paul II: “Love is also the richest source of the meaning of suffering, which always
remain a mystery: we are conscious of the insufficiency and inadequacy of our
explanation.”
 Medicine, as the science and also the art of healing, discovers in the vast field of human
sufferings the best known area, the one identified with greater precision and relatively
more counterbalanced by the methods of "reaction" (that is, the methods of therapy).
10
 Nonetheless, this is only one area. The field of human suffering is much wider, more
varied, and multi-dimensional. Man suffers in different ways, ways not always
considered by medicine, not even in its most advanced specializations. Suffering is
something which is still wider than sickness, more complex and at the same time still
more deeply rooted in humanity itself. A certain idea of this problem comes to us from
the distinction between physical suffering and moral suffering. This distinction is based
upon the double dimension of the human being and indicates the bodily and spiritual
element as the immediate or direct subject of suffering. Insofar as the words "suffering"
and "pain", can, up to a certain degree, be used as synonyms, physical suffering is
present when "the body is hurting" in some way, whereas moral suffering is "pain of the
soul". In fact, it is a question of pain of a spiritual nature, and not only of the
"psychological" dimension of pain which accompanies both moral and physical suffering
The vastness and the many forms of moral suffering are certainly no less in number than
the forms of physical suffering. But at the same time, moral suffering seems as it were
less identified and less reachable by therapy. (JPII, Salvifici Doloris, 5)
 Jesus is not alien to suffering and in fact, He identifies himself with those who suffer:
Christ's compassion toward the sick and his many healings of every kind of infirmity are
a resplendent sign that "God has visited his people "and that the Kingdom of God is
close at hand. Jesus has the power not only to heal, but also to forgive sins; he has come
to heal the whole man, soul, and body; he is the physician the sick has need of. His
compassion toward all who suffer goes so far that he identifies himself with them: "I
was sick, and you visited me." His preferential love for the sick has not ceased through
the centuries to draw the very special attention of Christians toward all those who suffer
in body and soul. It is the source of tireless efforts to comfort them. (Catechism of the
Catholic Church, 1503)
 God had not wished to include in man’s destiny suffering and death. They were
introduced by sin. But he, the Father of mercy, took them into his own hands, made
them pass through the body, the veins, the heart of his beloved Son, God like himself,
become man for the salvation of the world. And thus suffering and death became for
everyman who accepts Christ, a means of redemption and sanctification. And thus
man’s pilgrimage here below, continually shadowed by the sign of the cross and the law
of suffering and death, develops and purifies the soul, and leads it to happiness without
end in eternal life. (Pope Pius XII Christian Principles and the Medical Profession)
 One can say that with the Passion of Christ all human suffering has found itself in a new
situation. And it is as though Job has foreseen this when he said: "I know that my
Redeemer lives ...", and as though he had directed towards it his own suffering, which
without the Redemption could not have revealed to him the fullness of its meaning…In
the Cross of Christ not only is the Redemption accomplished through suffering, but also
human suffering itself has been redeemed, Christ, - without any fault of his own - took
on himself "the total evil of sin". The experience of this evil determined the

11
 incomparable extent of Christ's suffering, which became the price of the Redemption.
(JPII, Salvifici Doloris, 19)
As a ministry, hospice care participates in the salvific meaning of human suffering. As the pain
is managed, questions about human suffering arise. One can only find the answer to these
questions in the suffering of Christ, who suffers voluntarily and innocently. Suffering is the way
to mount the cross, the way to unite with the love of Christ.
 The world of human suffering unceasingly calls for, so to speak, another world: the
world of human love; and in a certain sense man owes to suffering that unselfish love
which stirs in his heart and actions. The person who is a " neighbor" cannot indifferently
pass by the suffering of another: this in the name of fundamental human solidarity, still
more in the name of love of neighbor. He must "stop", "sympathize", just like the
Samaritan of the Gospel parable. The parable in itself expresses a deeply Christian truth,
but one that at the same time is very universally human. It is not without reason that,
also in ordinary speech, any activity on behalf of the suffering and needy is called "Good
Samaritan" work. (JPII Salvifici Doloris, 29)
 Institutions which from generation to generation have performed "Good Samaritan"
service have developed and specialized even further in our times. This undoubtedly
proves that people today pay ever greater and closer attention to the sufferings of their
neighbor, seek to understand those sufferings and deal with them with ever greater
skill. They also have an ever greater capacity and specialization in this area. In view of all
this, we can say that the parable of the Samaritan of the Gospel has become one of the
essential elements of moral culture and universally human civilization. And thinking of
all those who by their knowledge and ability provide many kinds of service to their
suffering neighbor, we cannot but offer them words of thanks and gratitude. (JPII
Salvifici Doloris, 29)
 The sacrament of the sick strengthens the Christian in the affliction of suffering and
death. It would be wrong to consider this sacrament exclusively as a preparation for
death. In the Letter of James the sacred anointing is considered much more as a help to
heal the sick body (Jas 5,14). The Church ardently desires that Christians who are sick
should not neglect the grace offered them by the sacrament of anointing, and that those
around the sick should help them in this regard, particularly summoning a priest.
(Peschke, 355)

Source: Gross, Suzanne F.S.E and Marie Hillard, R.N. Palliative Care, Pain Management and
Human Suffering in Catholic Health Care Ethics: A Manual for Practitioners. Philadelphia, PA:
The National Catholic Bioethics Center. 2009.
Peschke, Karl. Christian Ethics: Moral Theology in Light of Vatican II Volume 2 Special Moral
Theology (Newly Revised Edition). Eugene, OR: Wipf and Stock Publishers. 2010.

12
Catechism of the Catholic Church.
United States Conference of Catholic Bishops. Ethical and Religious Directives for Catholic
Health Care Services. 2009
John Paul II. Evangelium Vitae. Vatican. March 25, 1995.
Congregation for the Doctrine of the Faith. Declaration on Euthanasia
Congregation for the Doctrine of the Faith. Samaritanus Bonus: on the care of persons in the
critical and terminal phases of life.

DNR ORDERS
The moral argument of DNR orders lies on whether to forego, withhold or withdraw treatment
as death is already foreseen. They mays also present themselves as alternatives that are in
conflict with each other and occasionally mutually exclusive. Prolongation of life at times
means prolongation of hopeless suffering (Peschke, 274). Merely maintaining life, especially at
the biological level, is not the purpose of human life. Life, health and all temporal goods are
subordinated to the purpose of life (O’Rourke, 66).
Medical conscience must learn to be willing not only to begin treatment but also to stop it. As a
protection against unwanted CPR, the practice has risen of writing do-not-resuscitate orders
(DNR), when requested by the patient or appropriate proxy.
While the Church teaching has not directly addressed the issue of DNR, there are teachings in
place that address the issue:
 It is understood that supporting life is always obligatory unless certain conditions are
met, namely, that the intervention has become excessively burdensome to the patient
or others, or that there is a disproportion between the burden of the intervention and
the hoped-for benefit.
 It does not prohibit the use of DNR orders provided that any intervention into a person’s
life should be an expression of Christian love, it should really be of eternal benefit to
that individual, and generally that same love would also consider the temporal well-
being of the individual so long as it does not interfere with the person’s eternal welfare.
 Since every person has the basic right and obligation to maintain and preserve his or her
life and has the right to those means necessary to carry out responsibly that obligation,
the person can decide whether or not to have CPR performed on them. Advance
directives are sometimes done, and these directives usually state the conditions under
which CPR or other life-prolonging procedures are to be used or withheld.
 If someone’s life has already been despaired of, then there is no need to prolong it
indefinitely by means of medicines and equipment, especially if the life in question is

13
 purely vegetal, without signs of human reaction. In this case all extraordinary means
may be omitted and the natural process allowed to take its course.
 Euthanasia must be distinguished from the decision to forego so-called "aggressive
medical treatment", in other words, medical procedures which no longer correspond to
the real situation of the patient, either because they are by now disproportionate to any
expected results or because they impose an excessive burden on the patient and his
family. In such situations, when death is clearly imminent and inevitable, one can in
conscience "refuse forms of treatment that would only secure a precarious and
burdensome prolongation of life, so long as the normal care due to the sick person in
similar cases is not interrupted". Certainly there is a moral obligation to care for oneself
and to allow oneself to be cared for, but this duty must take account of concrete
circumstances. It needs to be determined whether the means of treatment available are
objectively proportionate to the prospects for improvement. To forego extraordinary or
disproportionate means is not the equivalent of suicide or euthanasia; it rather
expresses acceptance of the human condition in the face of death. (EV, 65)
The DNR order is morally acceptable according to Catholic teaching if in the particular case it
has been properly determined that resuscitation would be ethically extraordinary means of
sustaining life. It is like an advance medical directive, in which the patient’s wishes regarding
future health care decisions are articulated before the need for these decisions in case the
patient lacks the capacity to make the decisions later. In the case of a DNR order, the advance
directive is specifically about resuscitation measures. It is very important that the patient’s
family and surrogate decision maker are clear about what constitutes resuscitation and why it
would not be ethically obligatory under the circumstances.
 A person has a moral obligation to use ordinary or proportionate means of preserving
his or her life. Proportionate means are those that in the judgment of the patient offer a
reasonable hope of benefit and do not entail an excessive burden or impose excessive
expense on the family or the community. (ERDCHCS, 56)
 A person may forgo extraordinary or disproportionate means of preserving life.
Disproportionate means are those that in the patient’s judgment do not offer a
reasonable hope of benefit or entail an excessive burden or impose excessive expense
on the family or the community. (ERDCHCS, 57)
 The free and informed judgment made by a competent adult patient concerning the use
or withdrawal of life-sustaining procedures should always be respected and normally
complied with, unless it is contrary to Catholic moral teaching. (ERDCHCS, 59)
 Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or
disproportionate to the expected outcome can be legitimate; it is the refusal of "over-
zealous" treatment. Here one does not will to cause death; one's inability to impede it is
merely accepted. The decisions should be made by the patient if he is competent and
able or, if not, by those legally entitled to act for the patient, whose reasonable will and
legitimate interests must always be respected. (CCC 2278)
14
Finally, in facing death, we are reminded that we are united with Crist in his suffering and
death, the death of the Christian is also filled with the hope of immortality and resurrection and
of final union with Christ. Since dying means perfect union with Christ, death for the Christian
is in the last analysis a gain. Of course the desire of death can also have its origin in less perfect
motives, such as impatience resulting from temporal misfortune or tiredness with the ordinary
hardships of life. But it is perfectly lawful when the desire to leave this world – as in the case of
Paul – is inspired by the wish for union with Christ in heaven and for eternal rest in God.
(Peschke, 356-357)

Source: Moraczewski, Albert O.P. Do-Not-Resuscitate Orders in Catholic Health Care Ethics: A
Manual for Practitioners. Philadelphia, PA: The National Catholic Bioethics Center. 2009.
Peschke, Karl. Christian Ethics: Moral Theology in Light of Vatican II Volume 2 Special Moral
Theology (Newly Revised Edition). Eugene, OR: Wipf and Stock Publishers. 2010.
USCCB. Ethical and Religious Directives for Catholic Health Care Services.
John Paul II. Evangelium Vitae.

15