Euthanasia and faith-based aged-care organisations: The right not to kill?

Abstract

In this paper we focus on an important specific issue which has not received serious attention in the scholarly literature on euthanasia, namely, that of the coercive imposition (by way of sanction-backed regulations) of the practice of voluntary active euthanasia (in particular) on faith-based, aged-care organizations. In Section 1 we outline the relevant conceptual background drawing on existing literature. In Section 2, we consider two conflicting ethical standpoints on voluntary active euthanasia. In Section 3 we outline the nature and extent of the push to impose the practice of voluntary active euthanasia on Catholic-run aged-care organizations. In Section 4 we argue that the argument for coercively imposing the practice of voluntary active euthanasia on faith-based, aged-care organizations, is not well-made, especially in the context of liberal democracies committed to pluralism.

Keywords:

• Catholic church
• euthanasia
• rights
• ethics
• church communication

Introduction

In this paper we do not seek to add to the well-worn, controversial, indeed protracted, generalized debates on the rights and wrongs of euthanasia as such. Rather we focus on an important specific issue which has not received serious attention in the scholarly literature on euthanasia, namely, that of the coercive imposition (by way of sanction-backed regulations) of the practice of euthanasia on faith-based, aged-care organizations. In Section 1 we outline the relevant conceptual background, drawing on existing literature. In Section 2, we consider two conflicting ethical standpoints on euthanasia policies in faith-based aged-care organizations and, specifically, in aged-care organizations run by the Catholic Church. In doing so we canvass the main arguments in the literature advanced by both the Catholic Church and her detractors. We argue that the Catholic Church’s standpoint on euthanasia is not obviously false or demonstrably incoherent, and enjoys widespread, even if minority, community support. In Section 3 we outline the nature and extent of the push to impose the practice of euthanasia on Catholic-run aged-care organizations. In Section 4 we address this ethical issue directly. We argue that the argument for coercively imposing (by way of sanction-backed regulations) the practice of euthanasia on faith-based, aged-care organizations, and Catholic-run ones in particular, is not well-made since (as argued in Section 2) one of its key premises is contestable. However, we go further and argue that the practice of euthanasia should not be coercively imposed on faith-based, aged-care organizations, and not simply on grounds of conscientious objection (an exemption right of individuals, such as the rights of pacifists in wartime). In doing so we invoke the moral right not to kill as it might apply to members of an occupation or institution qua members of that occupation or institution (Miller 2010, Ch. 2). We stress that extinguishing occupational/institutional rights undermines occupations/institutions, even if individual exemption rights are retained. By way of analogy, extinguishing the moral right and duty of military doctors qua doctors to provide medical assistance to enemy combatants would ultimately undermine the profession of doctor, even if each individual doctor could, if he or she chose, argue for an exemption in his or her particular case.

Section 1: Euthanasia: the conceptual background

Euthanasia involves the intentional ending of the life of a person by another person in order to end his or her suffering, or otherwise, by some definitions, for his or her own good, e.g. a doctor gives a lethal injection to a terminally ill patient in order to end the patient’s extreme pain from which there is no relief other than death (Vanderpool 2021). Assisted suicide is different from but associated with euthanasia. Unlike euthanasia, suicide is the act of killing oneself. Assisted suicide is the act of intentionally assisting another person to kill himself. For instance, if a relative of a person with a terminal illness obtained strong sedatives knowing the person intended to use them to kill himself and in fact he did so, the relative has assisted his suicide. Here we note that there are different definitions of euthanasia (Marcoux 2011). In this section we lay out the conceptual background necessary for our discussion.

There are two sets of distinctions that now need to be made in relation to euthanasia (Beauchamp and Davidson 1979; Finnis 1995; Foot 1997; Rachels 1986; Sumner 2017). The first set consists of a threefold distinction: voluntary, involuntary and non-voluntary actions. A voluntary action is one to which a person has given informed consent. An involuntary action is one to which a person has not in fact given informed consent, albeit he or she could have. A non-voluntary action is one performed by a person who does not have the ability to give informed consent, e.g. he or she suffers from some severe cognitive impairment.

The second set consists of the distinction between doing and allowing (Foot 1984; Quinn 1989; Scheffler 2004). Notice that actions (or omissions) that are done or allowed are typically, but not necessarily, intentional. If one intentionally performs an action or intentionally allows an outcome to occur (either by an omission or by discontinuing an action) then the action or outcome is not accidental or merely foreseen. So, the doing/allowing distinction is not to be confused with the intention/foreseen consequences distinction (and the so-called principle of double effect) (Aquinas 1988, Summa Theologica II-II, Q. 64, art. 7; Baumgarth and Regan 1988; Foot 1994; Quinn 1989). Accordingly, if a doctor intentionally gives a terminally ill cancer patient suffering extreme pain a lethal injection at the patient’s request this is an action; specifically, an action of killing the patient, albeit an action that some regard as morally justified. On the other hand, if the doctor discontinues the provision of a life-prolonging treatment to this patient at the patient’s request, with the sole intention of ending the suffering of the patient at the patient’s request and, as a result, the patient dies sooner rather than later, then the doctor has allowed the patient to die but the doctor has not performed the action of killing the patient. Moreover, the death of the patient is not intended (the doctor’s sole intention is to relieve the patient’s suffering at the patient’s request), although it is presumably a foreseen consequence of discontinuing the treatment. Arguably, the distinction between doing and allowing and, specifically, the distinction between killing and allowing to die is morally significant; it is morally worse, other things being equal, to kill someone than it is to allow them to die. Euthanasia that involves killing a person is typically referred to as active euthanasia while euthanasia that involves allowing someone to die by intentional refraining from assisting or withdrawing one’s assistance once given is typically referred to as passive euthanasia (Brassington 2020). For example, if medical professionals withdraw feeding tubes or turn off life support machines, or withdraw drugs that are keeping the patient alive then this is typically referred to as passive euthanasia. The distinction between active and passive euthanasia is important in law and in policy since in many jurisdictions, such as Germany, India and Mexico, active euthanasia may be unlawful but passive euthanasia (on some definitions) may not be unlawful (World Population Review 2023).

In addition to the distinction between doing and allowing, arguably, the distinction between intentions and foreseen consequences is morally significant; it is morally worse, other things being equal, to intend to kill someone (or intentionally allow them to die) than it is for their death to be an unintended but foreseen consequence of one’s action (or allowing). Putative cases of euthanasia in which death is a foreseen but unintended consequence of a doctor’s action or allowing are, it might be argued, not in reality instances of euthanasia. If so, then passive euthanasia necessarily involves an intention to allow a patient to die (and not merely an intention to refrain from assisting or intentionally withdrawing assistance once given). Thus, Brassington states: ‘Withholding life-sustaining treatment when death is not the intended outcome – and it may not be – is not euthanasia at all, passive or otherwise’ (Brassington 2020, 12). We agree with Brassington: passive euthanasia entails an intention to allow a patient to die (as, of course, does active euthanasia). However, in doing so we note that while there is a conceptual distinction between intentions and foreseen consequences, it is not always easy to determine whether a foreseen consequence of an action was in fact intended. In our above example, for instance, it might be argued that in fact the doctor must have intended to allow the patient to die.

These distinctions between active and passive euthanasia, and between voluntary, involuntary and non-voluntary euthanasia, generate six types of euthanasia or, at least, what we will refer to as euthanasia in this paper since, as already noted, there are some semantic debates regarding the term.¹ The six types are: (1) Voluntary active euthanasia; (2) voluntary passive euthanasia; (3) involuntary active euthanasia; (4) involuntary passive euthanasia; (5) non-voluntary active euthanasia; (6) non-voluntary passive euthanasia. In addition to this there are cases of assisted suicide.

Most individuals, organizations and legislators are opposed to involuntary active and passive euthanasia ((3) and (4) above) on the grounds that if the patient is able to give his or her informed consent to euthanasia and refuses to do so, i.e. it would be a violation of the patient’s autonomy to euthanize him or her. Thus, informed consent is regarded as a necessary condition for euthanasia, at least for those persons who are able to give it. Moreover, many individuals, organizations and legislators permit, at least in principle, some types of voluntary and non-voluntary passive euthanasia as we have defined these terms (i.e. (2) and (6) above). Accordingly, one important area of controversy concerns voluntary active euthanasia and non-voluntary active euthanasia, again, as we have defined these terms (i.e. (1) and (5) above).

In respect of these controversies, there are a complex set of considerations that tend to be in play. Firstly, there are the considerations with respect to the circumstances under which active or passive euthanasia is (rightly or wrongly) argued to be morally and legally permissible. These considerations include; (a) autonomy – in the case of voluntary active and passive euthanasia (but not non-voluntary euthanasia) the person has chosen to die; (b) terminal illness – the person has a limited period to live whatever happens, e.g. the person is suffering from terminal cancer; (c) extreme physical or psychological suffering which is unable to be relieved or ended, e.g. the person is in extreme physical pain; (d) extreme physical, sensory and/or cognitive impairment, e.g. the person is in a coma, and this impairment is irreversible.

Secondly, there are considerations in respect of the moral and legal rights and obligations of those actually or potentially involved in euthanasia, notably the patient to be euthanized, the physician who is to do the euthanizing, and the patient’s family. These considerations include the moral right to life. However, there are two other alleged moral rights that are invoked in relation to euthanasia, namely, the right to die and the right not to kill, that are of particular relevance to our concerns in this article. The right to die is often invoked by supporters of euthanasia, the right not to kill by opponents of it. We discuss these in detail in Section 4. Certain role-specific moral rights and obligations are also of particular relevance to our concerns in this article. Occupying a professional role, and indeed any institutional role, brings with it role-specific moral rights and obligations, the content of which are determined in part by the defining ends of the role, such as, in the case of doctors, saving lives, or by the defining ends of the institution in question, such as, in the case of the Church, salvation. Here we assume a neo-Aristotelian conception of occupational roles and institutions (Miller 2010; Oakley and Cocking 2001). Importantly, these institutional moral rights and obligations are not, at least in any straightforward way, necessarily derivable from so-called common morality (Alexandra and Miller 2009; Gert 2004). Nor are they necessarily derivable from the standard normative theories (for criticisms see Dancy 2004) which tend to be species of what might be referred to as value formalism, (e.g. consequentialism or contractarianism), or from prevailing ethical frameworks consisting of sets of high-level principles, including frameworks frequently used in the bioethics literature, e.g. the principles of autonomy, beneficence, non-malevolence and justice. One problem with these theories and principles is that they tend to downplay the array of constitutive natural features of human beings, including biological and social needs, and rational capacities, which ground and shape morality at least in the minimal sense that if the nature of human beings were different, e.g. if their basic needs (Wiggins 1998) were different, then their moral rights and obligations would also be different (Finnis 2011, 34). Moreover, their associated methodology tends to consist of the mechanical application of such prior formalist theories and frameworks to specific moral problems. However, this methodology is open to question, especially from approaches grounded in more substantive accounts of human beings as moral agents possessed of constitutive natural features (for instance, Aristotelian approaches: see Foot 2001) and, relatedly, more context sensitive approaches, e.g. approaches sensitive to institutional contexts (Miller 2010; Macintyre 1981). We discuss these various rights and obligations in relation to euthanasia in Section 4.

Section 2. Rights and wrongs of euthanasia: Catholic Church versus pro-euthanasia groups

Having provided ourselves with this conceptual framework in Section 1, let us now turn in this section to the conflict between, on the one hand, the ethico-religious beliefs and associated practices embedded in faith-based and, in particular, Catholic-based, healthcare organizations and, on the other hand, a prominent pro-euthanasia standpoint which not only advocates voluntary and non-voluntary active euthanasia (as well as passive euthanasia) in cases of extreme pain and suffering but also, in effect (as we will see in Section 3), the coercive imposition of their standpoint on the institutions of those who oppose it and, in particular, on Catholic institutions. In doing so it rejects the Catholic Church’s religious beliefs that underpin its anti-euthanasia standpoint. This pro-euthanasia, secularist/atheist position (as we will refer to it here notwithstanding that of course not all those who are secularists and/or atheists hold it) has been enshrined in the law in a number of countries, notably the Netherlands and Belgium.

The Catholic Church’s official position on euthanasia can be described as follows:

It is necessary to state firmly…that nothing and no one can in any way permit the killing of an innocent human being, whether a fetus or an embryo, an infant or an adult, an old person, or one suffering from an incurable disease, or a person who is dying. Furthermore, no one is permitted to ask for this act of killing, either for himself or herself or for another person entrusted to his or her care, nor can he or she consent to it, either explicitly or implicitly, nor can any authority legitimately recommend or permit such an action. For it is a question of the violation of the divine law, an offense against the dignity of the human person, a crime against life, and an attack on humanity. (Congregation for the Doctrine of the Faith 1980, ch.2)

The following is the Catholic Church’s official position regarding the discontinuation or withdrawal of medical procedures:

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. (Catechism of the Catholic Church 1993. n. 2278)

In 2004 Pope John Paul II released a statement about PVS, and in particular, the use of feeding tubes. His conclusion was that the use of feeding tubes was not a medical act, but rather a natural act. Furthermore, he remarks that the failure to administer food and water to a person ultimately results in starvation or dehydration, and if it is done willingly, is what he calls euthanasia by omission (passive euthanasia). Without leaving room for confusion, he remarks that to remove feeding tubes is, ‘a serious violation against the law of God, since it is the deliberate and morally unacceptable killing of a human person’ (John Paul II 2004, n. 4) (see also Francis 2017). Similarly, the Catholic Church does not permit any form of suicide including assisted suicide (Catechism 1993, n. 2282).

It is argued that to kill an innocent person is to oppose God’s love for that person and, therefore, to violate a fundamental right (Congregation for the Doctrine of the Faith 1980). We return to this issue in Section 4. Other concerns the Catholic Church has regarding euthanasia (voluntary active and passive euthanasia in terms of our definition) are as follows: (1) Euthanasia and assisted suicide are not safe because terminally ill people typically feel strong negative feelings that can cloud their judgement. Moreover, they are often susceptible to feelings of not wanting to be a burden to others, or to coercion from family members who do not want to be burdened with the terminally ill; (2) Euthanasia changes the doctor-patient relationship and is open to abuse and the erosion of the care of vulnerable people; (3) There has been a slippery slope in countries that have legalized euthanasia. For instance, when euthanasia was first introduced in Belgium in 2002 it was only available to terminally ill adults who could give full consent to the procedure. Euthanasia in Belgium is now available to children of aIll ages and to dementia patients; (4) Euthanasia is not the only option for people living with extreme pain and suffering. Good palliative care affords people the opportunity to die in comfort, often free from pain, or at the very least, with significantly reduced pain (Australian Catholic Bishop’s Conference 2020).

Those who advocate for voluntary active and passive euthanasia (and assisted suicide) generally make the following points which are contrary to the position of the Catholic Church, outlined above (Young 2017; Kuhse and Singer 1985): (1) A robust assessment of a patient requesting euthanasia should be sufficient to detect whether the request is the result is a true desire to die or if the request is the product of a clouded judgement. Moreover, the idea that the terminally ill cannot make serious decisions because of strong negative feelings denies the autonomy of the person; (2) If euthanasia is properly legislated it is less likely, or unlikely, to be open to abuse. Legislation may even protect patients from doctors and nurses who, legally and illegally, hasten death without the consent of the patient; (3) A commitment to the principle of double-effect and the wrongness of intentional killing, in particular, can unnecessarily prolong suffering (Jackson and Keown 2012); (4) Not everybody has access to good palliative care and palliative care cannot always remove the distress of the dying. Indeed, it is often claimed that euthanasia is a moral duty (Kohl 1992).

Clearly, the ethical debate concerning euthanasia continues. Indeed, according to Brassington (2020, 1): ‘Euthanasia is a controversial and emotive topic, but normative debate about it resembles trench warfare. People who are in favour of liberal laws tend to stay in favour of liberal laws, but rarely persuade those who aren’t to change their minds; and the same applies, mutatis mutandis, in respect of people who are in favour of tight restriction or criminalisation’.

That said, most would agree that the euthanasia of Tine Nys was unacceptable, or at the very least, at the extreme end of the euthanasia spectrum. Tine Nys was a 38 year-old woman who requested euthanasia in a state of depression after her relationship with her boyfriend ended. Her request for euthanasia was granted because her mental condition of autism, considered the root cause of her depression, was deemed to be incurable, and hence fit the legal criteria of euthanasia in Belgium (Kennedy Institute of Ethics 2020). This case was ultimately tested in court. The three doctors who participated in her death were cleared of the charge of manslaughter and wrongdoing (Peltier 2020). However, this case remains divisive.

Section 3. Legalised euthanasia and its impact on Catholic healthcare organisations

In Section 2 we detailed the Catholic Church’s view on euthanasia and the secularist/atheist view enshrined in legislation in various countries, i.e. the view that is not only pro-euthanasia but also advocates the coercive imposition of this view on Catholic institutions. Our specific concern in this section is the institutional, indeed legislative, push to require Catholic healthcare organizations to facilitate euthanasia.

Consider the following examples.

In Belgium a Catholic-run nursing-home refused to allow a resident, Mariette Buntjen, to be euthanized by her family doctor on the premises. Instead, an ambulance took the patient to her home where she was assisted to take her life. Buntjens’s family sued the nursing home for causing their mother ‘unnecessary mental and physical suffering’. A civil court in Louvain upheld the complaint, fined the home 3000 euros and ordered it to pay compensation of 1000 euros to each of Buntjens’s three adult children (Desanctis 2016). Thus, a court in Belgium ruled that the nursing home could not refuse to allow the woman to be euthanized on the premises if that was the agreement she had made with her family doctor. As a result of this case a debate concerning religious freedoms and euthanasia arose in Belgium. Notably, Archbishop Jozef De Kesel of Mechelen-Brussels argued that the Church had a right to deny euthanasia in its institutions. On the other side of the debate, it was argued that religious institutions must comply with the law because they receive state subsidies (Heneghan 2016). However, this argument does not stand scrutiny; he who pays the piper ought not necessarily call the tune, e.g. government subsidized independent media outlets, such as the BBC in the UK, ought not be prohibited from criticizing the government merely because they are subsidized by the government! At any rate, it is feared that this ruling of the court in Belgium could force many Catholic nursing homes in Belgium to lose their Catholic identity if they permit euthanasia on the premises (Caldwell 2017). This was the case for the Brothers of Charity.

The Brothers of Charity Organization, a Catholic religious order in Belgium which ran a group of psychiatric care centers, permitted doctors to perform euthanasia of ‘nonterminal’ mentally ill patients on its premises. This is contrary to Catholic doctrine, and the order rejected a formal request from their superior, outside of Belgium, to reverse their policy concerning euthanasia. However, this policy does harmonize the policies of the organization with Belgian law on euthanasia. Indeed, the organization claimed that it was necessary for the group to balance Catholic teaching on the sanctity of life with duty of care under the law and the demands of patient autonomy (Caldwell 2017). However, the Congregation for the Doctrine of the Faith ruled that the institution can no longer be called Catholic (Ladaria 2020). As a result of this, the religious order outside of Belgium successfully fought to prevent the care-centers from using the name of their order. Moreover, the superior of the order requested that the few remaining brothers, who largely worked in managerial roles in the care-centers, leave these positions immediately. Notwithstanding initial resistance to Catholic authorities in Rome, the president of the Brothers of Charity Organization, Raf De Ryke, who had wanted to retain the Catholic identity of the hospitals, announced that the order ‘let go’ of its psychiatric care-centers (Caldwell 2020). Here it is important to note that, according to Belgian law, institutions are prohibited from creating contractual clauses or other provisions that prohibit doctors working in their institutions from carrying out euthanasia. Yet, doctors and nurses may refuse to euthanize patients, or participate in euthanasia, on the basis of conscientious objection (The Catholic World Report 2020). However, there is an important distinction between the rights of institutions, such as the Catholic Church, and therefore the rights of their members qua members of those institutions (see Section 4), and the exemption rights of individuals. Extinguishing the former institutional rights will undermine the Catholic Church as an institution, even if the latter individual rights are retained.

Similar cases are expected to arise in other countries which permit euthanasia, given that many euthanasia lobbyists are intent on ensuring that euthanasia is performed in faith-based institutions that are government funded. Such was the motivation behind Jocelyn Downie’s campaign to pressure St Martha’s Catholic hospital in Antigonish, Nova Scotia to allow euthanasia on the premises. St Martha’s is the only hospital in Antigonish, and thus it was argued that it should provide euthanasia, which is legally available in Canada. In this instance a compromise was made and the, ironically named, Antigonish Health and Wellness Centre, which is not owned by St Martha’s but is on the same complex, agreed to perform euthanasia by lethal injection (Schadenberg 2019).

We also note that the policies of Catholic nursing homes opposed to euthanasia while operating in jurisdictions in which government legislation requires euthanasia to be available for those who want it is ethically problematic and in need of ethical analysis for the purpose of developing protocols consistent with Catholic teaching. In the state of Western Australia, for instance, according to the Catholic Weekly, the Catholic spokesperson, Dr Parkinson, outlined the WA Catholic health, aged care and disability sector polices regarding voluntary assisted dying (VAD) as follows (Catholic Weekly 2021):

Our services have agreed that we will not provide or facilitate VAD. To begin with, we recognise that wherever we deliver aged care or disability care services, it will usually be in the client or resident’s own home setting and they have a right (under Federal legislation) to make any other care arrangements they like. So, we cannot impede their right to seek Voluntary Assisted Dying (VAD) privately, and we will comply with the VAD Act in providing statutory information about VAD. However, we will not authorise any of our caregivers to be involved in any of the steps required for the client to access VAD, including facilitating assessments for eligibility and helping them to obtain and use the VAD substances. If a resident or client wishes to consult a VAD Navigator they will be able to do so privately, even on our premises, but our staff will not be authorised to assist, other than to put the resident or client in touch with the Navigator Service for the purposes of obtaining information. If a resident or client wishes to consult an external doctor for the purposes of VAD eligibility assessment and associated processes, they will be free to do so. However, Catholic sector staff will not assist in any way. It is also against the law for health care workers to raise the issue of voluntary assisted dying with a resident or client. If a resident or client wishes to make private arrangements to receive and use VAD substances they will not be impeded, but again our staff will not be authorised to assist in any way.

Thus, it is consistent with this policy for a nursing home to allow a patient to be assessed for eligibility for euthanasia by the patient’s own independent doctor (i.e. the doctor is not an employee or otherwise acting under the authority of the nursing home) in the context of a consultation conducted under conditions of doctor/patient confidentiality. Crucially, however, in doing so it will not allow the procedure to be performed in the nursing home as it conflicts with its religious beliefs (HOPE 2020) and nor will its staff assist the patient in relation to euthanasia. This is evidently an attempt to be consistent with Catholic teaching in so far as it does not involve actions that ‘formally cooperate in evil’, i.e. any ‘action that taken by its very nature, or by the configuration it is assuming in a concrete context, qualifies as direct participation [our italics] in an act against innocent human life, or as sharing the immoral intention of the principal agent’ (Congregation for the Doctrine of the Faith 2020, 4). On the other hand, the nursing home’s policy might, nevertheless, be argued to be inconsistent with the teaching of the Catholic Church regarding material support depending on how the notion of material support is understood in this context.²

However, even this conciliatory position of the WA Catholic health, aged care and disability sector might not be sustainable for Catholic-run healthcare agencies in many jurisdictions. For instance, there are concerns regarding conscience issues arising from assisted suicide in the USA, as well as in parts of Europe where euthanasia is more established. Regarding the USA, it is argued that there are provisions in place which prohibit all forms of government healthcare providers and health plans from discriminating against healthcare entities that do not facilitate euthanasia. However, it is also argued that the US government could decline to enforce the clause, as it did regarding conscience protections of the Weldon Amendment. The Weldon Amendment prohibits federal agencies, and state and local governments which receive Labor/HHS funds, from discriminating against health care entities that decline to facilitate abortions. This amendment was signed every year. However, the Office of Civil Rights (OCR) has refused to enforce the amendment in California, where healthcare-plans provided by churches and religious organizations have been forced to cover elective and late-term abortions (Desanctis 2016).

0.01w?>The push to force religious healthcare institutions to preform procedures which are not only morally repugnant but also forbidden to religious adherents is also coming from medical journals. For example, the New England Journal of Medicine, which is generally considered to be the most influential medical journal, published an article that challenged medical conscience rights. In this article (Wolfe and Pope 2020), two prominent bioethicists, Ian D. Wolfe and Thaddeus M. Pope argued that US states must create laws to ensure that Catholic hospitals provide medical procedures that are forbidden in Catholic teaching, particularly when Catholic (or religious affiliated) hospitals merge with secular hospitals or healthcare providers. Wolfe and Pope claim that too many US hospitals (one in six) are affiliated with the Catholic health system, which refuses certain procedures. In opposition to this, the Catholic position regarding their healthcare model is that it protects the vulnerable. Also, as stated above, in some jurisdictions it might be the position of some Catholic institutions not to actively prevent its patients from consulting with independent doctors who might refer them to non-Catholic institutions which conduct euthanasia.

Moreover, it is apparently not simply a matter of the coercive imposition of pro-euthanasia policies on Catholic institutions that is of concern. Although this might prove to be an isolated case, recently in Australia the government of the Australian Capital Territory forcibly acquired Calvary Hospital. The hospital was owned and run by the Little Company of Mary who did not consent to the acquisition of its hospital by the ACT government. However, in June 2023 the Health Infrastructure Enabling Bill was passed allowing the ACT government to own and run the hospital (Fenwicke 2023). This legislation includes a provision for police to enforce the acquisition should the need arise. The Catholic Archbishop of Sydney, Anthony Fisher, claims that the ACT government’s acquisition of the hospital was motivated by what he calls an ‘anti-life agenda’ (CathNews 2023).

Section 4. Conscientious objection and the right not to kill

As mentioned in Section 1, those involved in euthanasia, notably the patient to be euthanized, the physician who is to do the euthanizing, and the patient’s family, have various moral and legal rights and obligations. These include: (i) the moral right to life, including the derived moral right not to be killed and the concomitant moral and legal obligation not to kill, as well as the derived right to be saved and the concomitant moral and legal obligation to save life (if this can be done without undue risk or cost to the saver or if the saver’s institutional role requires it, e.g. he or she is a doctor); (ii) the moral and legal right, permission, and perhaps even obligation, to kill culpable attackers, if this is necessary to preserve one’s own life or the life of another or if the defender’s institutional role requires it, (e.g. he or she is a police officer or soldier). What is controversial in relation to euthanasia is that prima facie, at least, it is inconsistent with the deeply entrenched and uncontroversial moral right to life, and independent of, and perhaps even inconsistent with, the right to kill culpable attackers, since that right is derived in large part from the right to life, i.e. killing another human being is morally justified if it saves an innocent life and the person killed is morally culpable. At the very least, there is a deeply entrenched and uncontroversial moral presumption against intentionally killing another human being and, in particular, another innocent human being. On the other hand, as the moral and legal right to self-defense demonstrates, the right to life is not an absolute right; it can be overridden under certain circumstances.

Two other alleged moral rights that are invoked in relation to euthanasia are the right to die and the right not to kill. The right to die is often invoked by supporters of euthanasia (Young 2017; Kuhse and Singer 1985), the right not to kill by opponents of it (Finnis 1995, Keown 1995). The right not to kill is based in large part on the view that although life might not have an absolute value it, nevertheless, has a supreme or, at least, especially high moral value and that, therefore, to kill a human being is an especially egregious moral offence. One consideration in favor of this view is that life is a presupposition, and in part constitutive, of all other human goods, including autonomy; if one is killed then, of course, one no longer possesses autonomy, the ability to experience pleasure, and so on. At any rate, the right not to kill is, arguably, derivable from the right to life taken in conjunction with the right to autonomy. The idea is evidently that even if killing a person is morally justifiable, it would be morally wrong to coerce one person to kill another person.³ Naturally, other things being equal, coercion is morally wrong and wrong by virtue of undermining autonomy. However, given the moral weight that attaches to life, coercing one person to kill another person, is an extremely serious undermining of the autonomy of the person being coerced. Accordingly, the right not to kill is enshrined in the law in many jurisdictions in the form of conscientious objection legislation that allows, for instance, pacifists not to go to war. Indeed, conscientious objection for health-care workers in relation to abortion and euthanasia is well-established in many jurisdictions (Cowley 2020). Here it is important to stress that the right to conscientious objection in respect of the action of deliberately killing another human being – and especially one who is innocent – relies in large part on or, at the very least, derives significant moral weight from, the prior moral right not to kill. After all, conscientious objection is legally permissible in wartime, i.e. in circumstances in which there is a grave risk to the nation itself. Surely such a legal right is only justified by an underpinning moral right of great moral weight. What could this be other than a moral right not to kill? Thus, the point to be stressed here is the dependence of conscientious objection to killing on the prior right not to kill. As argued above, this prior right not to kill is in turn based on the right to autonomy (e.g. of the conscientious objector) taken in conjunction with the high moral value of life (e.g. the lives of those the conscientious objector is objecting to killing).

Note that if the high moral value of life is part of the basis of the right not to kill then this has implications for suicide, for assisted suicide and for euthanasia. Specifically, there might not be a moral right to commit suicide, given suicide is the destruction of something of high moral value, namely, (one’s own) life. Indeed, one might have a moral duty not to take one’s own life. In light of this, the argument against assisted suicide and euthanasia would not be framed in terms of having a moral right not to assist someone to do something that they have a moral right to do, namely, the right to take their own life. For ex-hypothesis they do not have a right to take their own life (other than perhaps in extreme circumstances). Rather the argument against assisted suicide and euthanasia would be framed in terms of the high moral value of life. Since a person’s life has high moral value they ought not to commit suicide and, therefore, I ought not assist them to take their life; nor should I kill them when they ask me to do so (active euthanasia) or intentionally allow them to die when they ask me to do so (passive euthanasia).

Moreover, it is now clear that the right not to kill is conceptually available to underpin rights other than the conscientious objection to killing. Specifically, it is available to underpin an institutional right; the right of a member of an institution, such as Catholic faith-based institutions, not to kill, i.e. not to engage in euthanasia. We note that, if so, then this institutional right of the member of an institution not to kill is also a moral right. As such, it may not attach to the institution per se (as a legal right might do) but rather to the members of the institution qua members of that institution (Miller 2010 Ch. 2 and Miller 2016 Ch. 3).

On the neo-Aristotelian normative account of institutions relied on here, institutions including aged-care organizations have as their telos or purpose the provision, directly or indirectly, of some collective good(s) (Miller 2010, Ch. 2). Thus police organizations (and, therefore, police officers) have as their purpose the maintenance of the collective good of security; universities (and, therefore, academics) the collective good of knowledge; hospitals (and, therefore, doctors and nurses) the collective good of health; the purpose of the Church (and, therefore, bishops and priests) is to serve the collective good of the mission of God in the world, and so on. The notion of a collective good is that of a good that is jointly produced, maintained or renewed by means of the joint activity of members of occupations, organizations or communities, e.g. schools, hospitals, police services, churches. Moreover, the moral rights and duties that are constitutive of institutional roles are in part derived from the collective good that is the raison d’etre of the relevant occupation, organization or community. Hence police officers have moral and legal rights to arrest offenders, academics have moral and institutional duties to teach, doctors have moral and professional duties in respect of their patients, priests have moral and institutional duties in respect of the teachings of Jesus Christ, and so on.

Importantly these institutional rights and duties that are also moral rights and duties may differ in various ways from the moral rights and duties of ordinary morality. For instance, police have a duty to put themselves in harm’s way above and beyond what is required of ordinary citizens, and doctors have a duty of care to their patients that ordinary citizens might not have. Importantly, these institutional rights and duties that are also moral rights and duties attach to the individual human beings who occupy the institutional roles in question, but attach to them qua occupants of these roles or qua members of the institution.

Thus, in the case of Catholic faith-based aged-care institutions, members have, qua members of these institutions, an institutional and moral right, indeed they may have an institutional and moral duty, not to engage in euthanasia. Note that this moral right (and perhaps duty) does not attach to the institution per se (as a legal right might do) but rather to the members of the institution qua members of that institution (Miller 2010, Ch.2).

What of the alleged moral right to die? Here we need to distinguish between an alleged right of a person to take his or her own life and the alleged right of a person to require of someone else that he or she take his life. While the former alleged right might be thought to be grounded in autonomy (and perhaps the special interest one has in one’s own life), the latter alleged right is far more difficult to establish, not the least because it is seemingly inconsistent with the right not to kill. Of course, if one has a moral right not to kill it might theoretically still be morally permissible for me to kill someone if, for instance, the person is terminally ill, suffering extreme pain, and asks me to take his or her life. However, this would not demonstrate that the person has a moral right to require me to kill him or her. It might also be the case that I have a moral obligation to kill a culpable attacker in self-defense. However, this is presumably because such a person has forfeited or perhaps suspended his or her right to life, i.e. it does not demonstrate that I do not have a right not to kill in cases where the person to be killed retains their right to life, as in cases of euthanasia.

A further point to be made here concerns role specific moral rights and obligations and was made in Section 1. To reiterate: The assumption of a professional role or, more generally, of an institutional role, brings with it role-specific moral rights and obligations, the content of which are determined in part by the defining end of the role, such as, in the case of doctors, saving lives, or by the defining ends of the institution in question, such as, in the case of the Church, salvation.⁴ These moral rights and obligations may not be consistent with performing euthanasia by doctors in any setting or by doctors or health-care workers in faith-based health-care institutions in particular (Miller and Miller 2021).

As we have just seen, the moral right to life can be overridden and hence it is morally permissible to kill another human being under some circumstances, and perhaps even obligatory to do so if, for instance, the person in question is morally culpable, e.g. is threatening the life of an innocent person. However, as we have also just seen the justification for a right to die is harder to find. This is especially the case if the alleged right to die is claimed to be a basic natural moral right and, therefore, a right all human beings possess by virtue of being human beings. The contrast here is with derived moral rights, and especially with institutional moral rights, such as the moral right of a surgeon to operate. The alleged basic natural moral right to die is especially difficult to establish given that there is a basic natural moral right to life grounded in the great moral weight that attaches to life as a presupposition and constitutive feature of all human goods. One argument mentioned above, which on closer scrutiny seems not to work, is the one based on autonomy; one has a right to take one’s own life, if one so chooses, by virtue of the overriding value of autonomy. However, even if autonomy is a higher value than life, it would not follow that one has a right to take one’s life by virtue of one’s autonomy, since to take one’s life would be to destroy (among other things) one’s autonomy.

If the moral right to die is not a basic natural moral right, perhaps there is nevertheless a moral obligation on the part of certain institutional actors, such as doctors, to kill persons who want to die – because, say, they are terminally ill and are suffering extreme pain. After all, it is suggested, other institutional actors, such as soldiers and police, are morally obliged to kill under certain circumstances. As we have already seen, killing culpable attackers, whether one is an ordinary citizen or a police officer or a soldier, is morally justified but does not demonstrate that there is a moral right to require others to kill oneself or others, since the person to be killed in such a case, unlike in cases of euthanasia, has presumably forfeited or suspended his or her right to life.

However, it might be argued that since soldiers, in particular, are often commanded by the superior officers to kill enemy combatants then there is no basic natural moral right not to kill. So, while the claim that there is a basic natural moral right to die is not correct, neither is the claim that there is a basic natural moral right not to kill, or so the argument would go.

Against this it might be claimed that whatever the legal situation, a soldier has a natural moral right to use or not use lethal force, assuming it is morally permissible in the circumstances in question (Miller 2016, Ch.3). In this respect soldiers are no different from police officers or ordinary civilians, it might be claimed. Moreover, arguably, neither a soldier nor anyone else can transfer this natural right to others. Nevertheless, the possibility of waiving this right remains. Accordingly, the response to the above argument against a basic natural moral right not to kill would require that soldiers, but not ordinary civilians, waive this natural right to use or not use lethal force in favor of their superior officers. They do so when they accept the institutional role of a military combatant and embark on a war. We note that, since it is a natural right, it is not conferred (as in the case of the surgeon’s right to operate). If this is correct, then it has an important implication for euthanasia.

It implies that the right not to kill is, after all, an inalienable natural moral right – it is a moral right with respect to one’s own lethal actions, as opposed to the lethal actions of others. Moreover, being an inalienable right, it cannot be transferred to others, such as to one’s institutional superiors (although it can be waived for a limited period under certain circumstances and delegated to others, including one’s superiors if one is a soldier in a theatre of war). This right that a person, A, has with respect to A’s own lethal actions is logically consistent with A’s lethal action being either morally obligatory or morally impermissible. The latter concerns the objective properties of A’s act or omission, whereas the former concerns the moral decision maker. It is one thing for a person to have the right to make a decision, and another for that person to make the right decision. Accordingly, a doctor, for instance, would have, as we all do and notwithstanding his or her institutional position, an inalienable basic natural moral right not to kill a patient, notwithstanding that the patient was terminally ill, suffering extreme pain and asking to be killed. It is, of course, as we have just seen, a separate matter whether or not the doctor, nevertheless, ought not to exercise this right by, for instance, killing the patient in these circumstances.

We have argued that there is a basic natural moral right not to kill, but not a basic natural moral right to die. Moreover, that this claim that there is a basic natural moral right not to kill is generally acknowledged is evidenced by longstanding legislation in most liberal democracies permitting conscientious objectors not to fight in wars. Moreover, even those who claim that there is a moral right to die seem to doubt its stringency. For instance, many euthanasia providers, including in the Netherlands and Belgium, deemed euthanasia to be an elective procedure and suspended their services amidst the deadliest stages of the Covid-19 crisis (Decker and Fresca 2001). Surely, if there was a stringent moral right to die it would not be deemed to be merely an elective procedure. This decision to deem euthanasia an elective procedure is in stark contrast to hospice services who continued their services to the dying despite all of the risks involved and the number of healthcare workers and doctors who were required for this service. Evidently the right to life is far morally weightier than the right to die, even supposing, as seems doubtful, that there was in fact a right to die.

It might be suggested that whereas we have made a compelling case for the moral right not to kill and, therefore, for doctors not to be required to engage in euthanasia if they are conscientious objectors, we have not made one in favor of allowing Catholic organizations per se not to engage in euthanasia. However, as we have seen, the right not to kill is a prior moral right which is conceptually available not only to underpin an individual’s conscientious objection to killing but also to underpin institutional rights, i.e. the rights of the members of an institution, such as the Catholic Church or its faith-based organizations, which seeks to embody (among other rights and principles) the right not to kill. Catholic institutions are, by definition, committed to enshrining their fundamental ethico-religious beliefs in their actual practices and, therefore, in the case of euthanasia by not engaging in or facilitating it. Accordingly, it is not simply a matter of individuals who are conscientious objectors being allowed to be exceptions in an otherwise secular organization, as in the case of the military. It follows that coercively imposing (by way of legislation) the requirement on Catholic healthcare institutions to facilitate euthanasia is tantamount to undermining those institutions qua Catholic institutions. But what could be the justification for that, other than ideological opposition to Catholicism (and perhaps Christianity?) per se? In particular, what could be the justification for that when euthanasia can be conducted elsewhere? Moreover, as argued in Section 2, the restrictive Catholic view opposing euthanasia is a widespread view in society, and the contrary permissive pro-euthanasia secularist/atheist view, while also widespread, cannot be intellectually established with any significant degree of certainty. In these circumstances in a pluralist society, surely the controversial permissive view on euthanasia antithetical to fundamental Catholic doctrine should not be coercively imposed (via legislation) on Catholic healthcare institutions.

Acknowledgments

Seumas Miller co-authored this article while he was a visiting scholar in the Faculty of Philosophy at the Pontifical Gregorian University in 2022.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Seumas Miller

Seumas Miller is a Professor of Philosophy at Charles Sturt University and a Distinguished Research Fellow at the Uehiro Centre for Practical Ethics at the University of Oxford. He specializes in professional and applied ethics. Miller has authored or co-authored over 200 academic articles and 20 books, including: (with A. Alexandra) The Moral Foundations of Social Institutions: A Study in Applied Philosophy (Cambridge University Press, 2010), Integrity Systems for Occupations (Routledge, 2016) and (with M Selgelid) Ethical and Philosophical Consideration of the Dual Use Dilemma in the Biological Sciences (Springer, 2008).

Virginia Miller

Virginia Miller is a research fellow at the Centre for Religion, Ethics and Society, Charles Sturt University. She is the author of many policy-focused works including, Child Sexual Abuse and the Catholic Church: Reassessing the Evidence (Florence University Press, 2021), Integrity Systems and the Anglican Church: Truth, Justice and Love (Cambridge, Journal of Anglican Studies) and Elderly Sexual Abuse in Residential Homes: Issues of Concern (Brill, International Journal of Public Theology).

Notes

1 For instance, the Catholic Church defines euthanasia in the following way: “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” (Congregation for the Doctrine of the Faith 1980, ch. 2). The Netherlands Government defines euthanasia in the following way: “Euthanasia is the termination of life by a physician at the patient’s request. The aim is to end unbearable suffering with no prospect of improvement. Physician-assisted suicide also falls under this definition” (Government of Netherlands 2021).

2 “Moral Cooperation in the Evil of Another.” https://www.ewtn.com/catholicism/answers/moral-cooperation-in-the-evil-of-another-23211.

3 Bernard Williams makes an analogous point in relation to being forced to murder someone (See Hollis 1983).

4 This assumes that the defining end of the occupation or institution in question is a good and, in some cases, this might be contestable. However, if we assume as we must that the institutions in question are morally legitimate ones then the ends that they serve will presumably be morally legitimate.