Author: Jimmy Akin

A reader writes:

Jimmy (may I presume to use your first name? If not, Mr. Akin):

I love listening to you on Catholic Answers — as they say in talk radio, I’m a long time listener, first time talker. Anyhow, your excellent discussion of the stem cell issue leads me to ask a different question on Catholic medical ethics:

Ken Lay died of a heart attack recently. If he had stopped taking heart medicine, thus hastening his death, would that be suicide? To what extent is someone required to take life-saving medicine?

The Catechism does not seem to contain a technical definition of suicide, so I’m going to have to fall back on my own understanding of the term, which is that suicide is undertaking a course of action in order to bring about one’s own death.

By undertaking a course of action, this doesn’t have to mean taking positive action, like putting a gun to one’s head or injecting a toxic drug into your body. It can also be refusing to do those things that would reasonably be expected of a person in an effort to preserve his life.

For example, if you found yourself in the middle of a busy street with a bus bearing down on you and you refused to step out of the way so that you could get run over and die then I would say that was suicide even though the "action" you performed was a refusal to do something (i.e., step out of the path of the bus).

For someone taking heart medicine (and I notice that you didn’t say Ken Lay was or that he discontinued taking it, you just used him as a hypothetical example), a refusal to take the medicine would seem to count as suicide if two conditions were fulfilled:

1) The person discontinued the medication in order to bring about their death, and
2) The personal was morally obligated to take the medication.

A person could discontinue taking the medicine without fulfilling condition (1) if there was some other reason for the discontinuation. For example, the person may have run out of the medicine and didn’t have the money to buy more and couldn’t find a source that would donate it to him. (This might be the case for many people with heart problems in the third world, for example.) It might also be that the heart medicine was causing horrible side effects (let’s say he developed a severe allergy to it) and the motive was to stop the allergic reactions rather than to bring about his own death. He might also have joined a religion that forbids the use of medicine.

If his motive was something other than bringing about his own death then I wouldn’t be inclined to call it suicide. I think that the intention to kill oneself is an indispensible part of suicide in the proper sense. It’s that intention that distinguishes suicide, for example, from recklessly endangering one’s life (i.e., taking unacceptable risks with it in the absence of the intention to kill oneself).

Note that the motive might or might not be a good one. If he has a good reason for discontinuing the medication (like, he simply can’t get any more) then if he dies as a result of not taking it then he has no moral culpability in his death. On the other hand, he might have a bad motive (like he just doesn’t like the color of the pills). In the latter case he would bear moral culpability for his death, though the sin would not be suicide in the proper sense since there was not an intent to bring about his own death (the intent being not to take pills of that color).

All this deals with the first condition necessary for suicide. Now let’s look at the second:

What medical treatments are morally obligatory? Historically, this question has been answered in terms of "extraordinary" vs. "ordinary" treatments. Those treatments that were ordinary were ones that a person was morally expected to perform, whlie extraordinary ones were not morally obligatory.

This distinction worked well in the 1500s, when medicine wasn’t changing very fast. People had an intuitive sense of what procedures were ordinary vs. extraordinary, but with the massive change in medical technology that we are currently in the middle of, treatments that were once not just extraordinary but impossible are now totally ordinary (e.g., taking your insulin if you’re a Type 1 diabetic).

Consequently, Catholic moral theology has been reframing the discussion not in terms of what is ordinary vs. extraordinary but what is proportionate vs. disproportionate. The Holy See’s 1980 Declaration on Euthanasia takes note of this:

In the past, moralists replied that one is never obliged to use "extraordinary" means. This reply, which as a principle still holds good, is perhaps less clear today, by reason of the imprecision of the term and the rapid progress made in the treatment of sickness. Thus some people prefer to speak of "proportionate" and "disproportionate" means.

The distinction between what is proportionate and what is disproportionate is dealt with by what the declaration goes on to say:

In any case, it will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources.

In other words, there is a cost:benefit analysis that needs to be performed, comparing the costs (pain, discomfort, side-effects, money) to the benefits he will receive. If the benefits clearly outweigh the costs then the procedure is proportionate to the problem it is trying to address. On the other hand, if the costs clearly outweigh the benefits then the procedure is disproportionate.

Now, whenever the word "proportionate" gets involved in a moral discussion, some folks are inclined to start lobbing accusations of "proportionalism," so I need to issue

THE BIG RED DISCLAIMER: What I am talking about here is not proportionalism. Proportionalism is a system of thought that makes the proportions of costs and benefits the ONLY criteria to be taken into account in a moral appraisal. That’s why it’s got the -ism tacked on to the end of "proportional," because it makes proportionality the be-all and end-all of moral theology.

Proportionalism is a false moral system, but not all discussion of proportionality means that someone is advocating proportionalism. Orthodox Catholic moral theologians discussion proportionality all the time. It’s just when it gets made into the exclusive criteria of morality that we have proportionalism.

And the Holy See is not averse to taking the proportionality of the costs to the benefits into account, as see from the quotation above and from what the Declaration on Euthanasia goes on to say:

It is also permitted, with the patient’s consent, to interrupt these [advanced or even experimental] means, where the results fall short of expectations. But for such a decision to be made, account will have to be taken of the reasonable wishes of the patient and the patient’s family, as also of the advice of the doctors who are specially competent in the matter. The latter may in particular judge that the investment in instruments and personnel is disproportionate to the results foreseen; they may also judge that the techniques applied impose on the patient strain or suffering out of proportion with the benefits which he or she may gain from such techniques.

The document also says:

Therefore one cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community.

When inevitable death is imminent in spite of the means used, it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted. In such circumstances the doctor has no reason to reproach himself with failing to help the person in danger.

So: It seems to me that whether a refusal to take one’s heart medicine is suicide will depend (1) on whether the persons is discontinuing it precisely in order to cause his death and (2) whether the use of the heart medicine is proportionate to the benefits it will give the patient.

If a person can reasonably afford the heart medicine and it is expected to keep him alive without causing horrible suffering then it seems to me that the use of the medicine is proportionate to the benefit to be achieved and thus he is morally obliged to take it.

If he refuses to take it in order to kill himself then it’s suicide. If he refuses to take it for some other inadequate reason then it is something else, such as reckless endangerment of his life.

Hope this helps!

A reader writes:

I wanted to pose a question given the Church’s teaching on embryonic stem cell research. I have a good friend that is suffering from a serious illness that will likely end her life earlier than average. This is an illness that, valid or not, numerous claims about stem cells being the source of a cure for this illness. For purposes of this question, let’s set aside the current practical understanding (ESCR hasn’t yielded any successful advances at this point, while adult stem cell research is more promising). Let’s assume that, at some point in the future (as ESCR is unfortunately likely to happen in private labs at the least), such research yields a complete cure for this illness. How does the current Church teaching extend to that scenario?

Currently, it is sinful for researchers to perform this and (correct me if I’m wrong) sinful to encourage or provide funding for it.

How does that apply to someone whose life would be extended if they receive that cure? If a cure is made available, does the Church teach that an individual will be committed a grave sin in receiving the cure?

Does it matter how the cure is developed (i.e., research yields a method that does not require killing off embryos – the initial research is sinful, what does that make the resulting method)? I’m not trying to look for a “loophole” here…I’m trying to grasp a better understanding of the application of the Church teaching so I can explain it better to my friend. Any help you could provide in explaining this better would be greatly appreciated.

This is an area of ongoing doctrinal development, so the best I can do is sketch the current shape of my own understanding of how to apply the relevant principles to this area. There may be medical facts I am unaware of, and the Church may later clarify things in a way that is different than what I sketch below.

Let’s start by being clear about what is intrinsically wrong here: killing embryonic human beings. That is the thing that is intrinsically wrong. Other things in this area are not intrinsically wrong–or have not been said by the Church to be instrinsically wrong–but may be extrinsically wrong based on how they relate to the killing of embryonic humans.

It is thus wrong to kill an embryonic human in order to develop a cell line out of his body, but it is not wrong–or has not been judged by the Church to be wrong–to extract stem cells from an adult (without killing him) in order to generate a cell line.

Once you’ve got the cell line, it is intrinsically possible to experiment on it and try to develop cures from it. The cell line is not a human being (unless you are culturing it in a way that results in the creation of zygotes, which may be the case in some instances) and so the cell line has no rights to be violated. Whether the cell line originated from an embryo who was killed or an adult who was not killed does not affect the moral character of experimenting on it as long as it does not give rise to new humans.

The source of concern at this point is whether conducting such experimentation–which is morally permitted in principle–is whether doing so will reward/encourage those who have killed embryos.

The Church is concerned to avoid the creation of widespread baby farming in order to get new cell lines for research. If allowing research on cells lines that came from murdered babies is something that will result in the murder of thousands or millions of more babies then–as a practical matter–refusing to allow the research may be the best way to protect human life (taking into account the lives that might not be saved because the research doesn’t get done). In this case doing/funding the research would be extrinsically wrong, meaning that it is not wrong in itself but is wrong because it promotes something that is wrong in itself.

Unfortunately, when things are extrinsically wrong it often is unclear what their moral status is. If something is wrong in and of itself then we can be more definite about its moral status than if we’re trying to figure out what kind of cooperation is involved in an action that is wrong. There is thus often a judgment call that has to be made when it comes to whether an immoral form of cooperation is present.

Thus far the Church has not issued a judgment that experimenting on cell lines from embryos is (a) intrinsically evil or (b) always extrinsically evil due to an inadmissable form of cooperation with embryo killing. In the absence of such a judgment, Catholic researchers would be allowed to hold the position that it is permissible for them to conduct research on embryonic stem cell lines as long as they are not creating zygotes or otherwise encouraging the destruction of embryos.

I strongly suspect, though, that if pressed the Vatican would also protect the right of Catholic researchers not to hold this opinion and to refuse to participate in the research.

Why do I say that?

Because there is also the question of how this impacts your friend: Supposing a cure were developed from such a cell line, could it be used?

Well, right now there are some treatments out there that, in one way or another, involve cells from aborted kids and the Holy See has defended the right of Catholics not to use these treatments even if they are required by local laws (e.g., as part of childhood vaccinations).

The current state of affairs is thus that the Church seems to permit Catholics to hold either position: that it is permissible to fund, research, or take treatments based on stem cell lines coming from embryos as long as one isn’t improperly cooperating in the deaths of new humans OR that one should refuse to fund, research, or take treatments based on such cell lines in order to avoid rewarding/encouraging those who would kill babies.

This is a tricky area, and I espect we will get more clarification from the Church in the future, but that is what seems to be the attitude it is taking for now.

Incidentally, this is not the only time that this kind of situation has come up. It also came up after World War II when it was discovered that the Nazis had done all kinds of medical experimentation on Jewish individuals and there was the question of what to do with the research they had amassed: use it or not?

We can adapt that situation a little bit to the case of stem cells in order to get at the central dilemma. What I’m about to say will be nightmarish, but we’re dealing with a nightmare scenario here, and it helps to remember that and to put a human face on it.

With embryonic stem cell research, what we’re talking about it killing children in order to get medical consumables from them that may then save lives.

Okay: So suppose that you are an Allied pilot who gets shot down over Nazi Germany and you are badly in need of a transfusion, without which you will die.

A Catholic doctor takes pity on you and offers you the transfusion, but he feels that you ought to know the source of the blood, and it turns out that the Nazis have been killing Jewish individuals specifically to get their blood for use in transfusions.

This morning the doctor received a shipment of blood of your type that was extracted from a little girl–Anne Frank–who was killed so that people like you could have her blood.

Do you take the transfusion or not?

It’s a nightmare scenario, but that’s the kind of thing we’re talking about.

Incidentally, one might note that Nazi Germany wasn’t a democracy and wouldn’t care about whether you refused the transfusion or not. On the other hand, we might note that while we are living in a democracy here in America, if widespread baby farming gets started then the drug companies and research labs won’t care about your individual refusal to take their treatments, either.

That’s the situation we’re left to wrestle with.

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