Valuing the elderly and keeping them socially connected

 

Staff of The Nathaniel Centre

We often read or hear the term 'grey tsunami' used to describe the large numbers of 'baby boomers' who are reaching the age of retirement, and we are increasingly warned about their negative economic impact, particularly the effects of a shrinking workforce and the increased demand for health care services. While many would challenge these assumptions, arguing for an alternative and more optimistic view based on people working past retirement and experiencing healthier years later in life due to improvements in diet and access to medical care, still it is the negative language that seems to prevail. The constant use of phrases such as 'old-age dependency ratio', 'decline in functional capacity' and 'the economic burden of an ageing population' to describe the elderly, arguably reveal more about ourselves and our attitudes to ageing than about the elderly – symptomatic of a society that fears growing old, that fears dependency and vulnerability and is willing to judge the elderly more and more in deficit terms, often through an economic filter.

The growing rates of elder abuse in New Zealand are well-documented and growing rates of social isolation amongst the elderly are further manifestations of a society in which the elderly are becoming disenfranchised and marginalised.

A recent article in the New Zealand Listener (April 4-10, 2015) describes a 'loneliness epidemic' affecting the elderly in this country. Recent New Zealand studies reveal that around 8 percent are severely lonely and up to 45 percent moderately lonely1. Meanwhile other research shows clearly that loneliness is related to lower levels of physical and mental health.

Many elderly people, but especially those who are socially isolated, suffer from depression2. The coroner's report for 2014 found that the number of suicides recorded in over-60 year olds went up from 75 in 2012-13 to 97 in 2013-14. "The rise in older people taking their own lives is something I highlighted last year, and this trend has continued, particularly for the above-80-year-old age cohort."3 We also know that in places where assisted suicide or euthanasia is available, the most common end of life concerns are not pain-related but existential, including loss of autonomy, fear of being a burden, a decreasing ability to participate in activities that made life enjoyable, fear of losing control and social isolation4.

The isolation of the elderly is partly explained by the fact that families are smaller, more fragmented and more likely to be geographically dispersed. Significant numbers of the elderly now live in different cities and even different countries than their children or their siblings, and even when living nearby, adult children are often 'time poor' – i.e. busy with their own children and jobs.

Where elder abuse is happening, families are very often part of the problem; 50 percent of alleged abusers are family members, usually sons and daughters. It is conservatively estimated that around 9,000 older New Zealanders suffer some sort of abuse or neglect each year,5 psychological abuse being the most common, followed by financial abuse. Loneliness or isolation is a known risk factor for abuse, and often the abuse is not reported due to feelings of shame.

The isolation, loneliness and abuse of the elderly are symptomatic of a culture that views the elderly as having outlived their usefulness. This has been described as 'ageism', a systematic stereotyping of people because they are old which leads to them being viewed as "lesser beings, asexual, intellectually inflexible and at the same time forgetful and unproductive."6 Describing this shift, Pope Francis has repeatedly criticised the fact that the elderly are ignored, or seen as a burden who do not produce and can be discarded: "Then when we become older, especially if we are poor, sick and alone, we experience the shortcomings of a society planned on efficiency, which consequently ignores the elderly." Pope Francis warns of a 'poisonous' culture where the elderly are 'abandoned in institutions' where they may suffer physical neglect or loneliness. He sees older people and children as being particularly at risk because they are not economically productive. "But this culture of 'discarding' human beings hurts our world ... How many times we discard older people with attitudes that are akin to a hidden form of euthanasia."7

Thankfully, there are various commentators who are challenging the utilitarian view of the elderly exemplified in a number of extremely positive and imaginative developments taking place internationally.

Atul Gawande, for example, writes of 'nursing home' managers in the United States who have questioned the rigid focus on safety and have given autonomy back to the residents in a variety of ways. He describes how in one home the new Medical Director found 'despair in every room' and identified the 'three plagues' of nursing home existence as boredom, loneliness and helplessness. The response of the new Director was to inject life back into the home in the form of animals, plants and people: "The inhabitants of Chase Memorial Nursing Home now included one hundred parakeets, four dogs, two cats, plus a colony of rabbits and a flock of laying hens. There were also hundreds of indoor plants and a thriving vegetable and flower garden. The home had on-site child care for the staff and a new after-school programme. Researchers studied the effects of this programme over two years, comparing a variety of measures for Chase's residents with those of residents at another nursing home nearby. Their study found that the number of prescriptions required per resident fell to half that of the control nursing home. Psycho¬tropic drugs for agitation, like Haldol, decreased in particular. The total drug costs fell to only 38 per cent of the comparison facility. Deaths fell 15 per cent. The study couldn't say why. But Thomas [the Medical Director] thought he could. 'I believe that the difference in death rates can be traced to the fundamental human need for a reason to live' ... The most important finding was that it is possible to provide them with reasons to live, period. Even residents with dementia so severe that they had lost the ability to grasp much of what was going on could experience a life with greater meaning and pleasure and satisfaction."8

In the Netherlands there is now a nursing home that allows students to live there for free in exchange for spending at least 30 hours a month with the home's senior citizens. "They go see the pensioners for a chat, they play games, go with them to the shopping centre, (and) do shopping for those who can't."9 The students also cook meals and plan activities based on their interests. For example, one student provided a group who were curious about graffiti with spray cans and cardboard to help them learn about the art form.

Meanwhile a nursing home in Seattle has pre-schoolers come in for their classes and to spend time with the elderly. The pre-schoolers come with "no assumptions, no judgement and no awkwardness – just lots of time to spend and heaps of love to give."10 Filmmaker Evan Briggs shot a film of the retirement home over the year 2012-2013; she said residents had a "complete transformation in the presence of the children. Moments before the kids came in, sometimes the people seemed half alive, sometimes asleep. It was a depressing scene. As soon as the kids walked in for art or music or making sandwiches for the homeless or whatever the project that day was, the residents came alive."11 As the school describes, the program has benefits for both the children and the elderly; the elderly find a new sense of self-worth and enjoy the joy and laughter that toddlers bring to any setting. The children learn about the aging process, learn to accept people with disabilities and receive unconditional love and attention from the residents12.


A community-based initiative closer to home, operated by St Joseph's Malvern parish in Melbourne, engages residents as volunteers or recipients for services offered by Jo Care.13 Theirs is a free service aimed at encouraging friendship and support within the local area. The volunteers might visit for a chat, share a book, go for a walk, or teach a new skill, but the focus of the program is to engage with socially isolated individuals.

In Limerick, Ireland, there is The Compassionate Communities Project14 which works in partnership with individuals, groups and communities to provide a range of support to people living with a serious life-threatening illness, as well as those facing loss and those experiencing bereavement. One of their groups, the Good Neighbourhood Partnership15 , has volunteers providing social and practical support to people with palliative care needs. The aim of the project is to enable people to identify their social and practical needs and have them met from within their own circle of community. The project had identified that often friends and neighbours want to help but are sometimes unsure how to. The Partnership makes links between those who need social and practical support and those living close-by who would like to offer help. Activities include "walking the dog, doing the shopping, collecting a prescription, going to the library, filling a coal bucket, lighting the fire, mowing the lawn, making a snack, tidying up or sitting with a person who needs a break."16

Developments such as these provide real and effective opportunities to challenge the growing spread of ageism; they have the potential to help us all view the elderly differently, understand better the contribution that they make to the community, allow them real value and dignity, and at the same time enrich our communities with demonstrations of care and compassion.


Staff of The Nathaniel Centre

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[1] An Auckland Council commissioned study found that 9 percent of Auckland residents aged over 50 were severely lonely and 44.5 percent moderately lonely; the New Zealand Longitudinal Study of Aging found that 3 percent of those between the ages of 48 and 90 years were very severely lonely, 7 percent were severely lonely and 41.2 percent were moderately lonely.

[2] Depression affects 15-20 percent of older people. Ministry of Health: Mental Health and Addiction Services for Older People and Dementia Services. 2011. http://www.health.govt.nz/system/files/documents/publications/mental-health-addiction-services-20jun.pdf

[3] Report of Chief Coroner 20 August 2014. http://www.justice.govt.nz/courts/coroners-court/suicide-in-new-zealand/suicide-statistics-1/2013-14-annual-suicide-stats-press-release

[4] See “‘Be Careful what you wish for.’ Euthanasia and Rob Jonquiere’s ‘ideal’ society”. The Nathaniel Report, issue 45, pp. 4-5.

[5] Age Concern reports 1500 confirmed cases of elder abuse or neglect; it is estimated that only 16% of all abuse incidents come to the attention of service agencies. https://www.ageconcern.org.nz/ACNZPublic/Services/EANP/ACNZ_Public/Elder_Abuse_and_Neglect.aspx#howmuch

[6] Families Commission: Elder Abuse and Neglect. Exploration of Risk and Protective Factors. Research Report No. 1/08, January 2008. P. 16

[7] See http://www.thetablet.co.uk/news/1224/0/pope-francis-likens-neglect-of-older-people-to-hidden-euthanasia-

[8] Gawande, Atul “Being Mortal: Illness, Medicine and What Matters in the End”. Profile Books Ltd, London. 2014.

[9] See http://thehigherlearning.com/?s=a+Dutch+nursing+home

[10] See http://www.mercatornet.com/family_edge/view/video-preschool-meets-nursing-homes/16358

[11] See https://gma.yahoo.com/seattle-preschool-nursing-home-transforms-elderly-residents-201932520--abc-news-parenting.html

[12] http://washington.providence.org/senior-care/mount-st-vincent/services/child-care/

[13] See http://stjosephsmalvern.org.au/jocare/

[14] http://www.compassionatecommunities.ie/

[15] http://www.compassionatecommunities.ie/#!good-neighbour-partnership/czul

[16] See http://www.compassionatecommunities.ie/#!good-neighbour-partnership/czul

‘Be careful what you wish for.’ Euthanasia and Rob Jonquiere’s ‘ideal’ society

 

John Kleinsman

 

An uncle of mine often used to quip: 'Be careful what you wish for!' It's a reminder that things we desire often come with unforeseen and undesirable consequences. If there was ever an instance in which this applies it is in regard to euthanasia and assisted-suicide

Proponents of a law change believe the issue is fundamentally about 'choice'. Allowing those who want it to choose when and how they die would not affect those who think otherwise, it is argued. Euthanasia/assisted-suicide can seem acceptable, fair and safe when the focus is solely on individual 'hard' cases.

As someone opposed to euthanasia and assisted suicide, I am often accused of imposing my choices on others. Actually, I don't have a problem with people exercising choice. In an 'ideal' world, a world of total empathy and inclusion, a world of equitable access to health care in which the elderly were truly valued, I could live with people being given this choice. But we don't live in such a world.

A robust, informed debate about euthanasia and assisted-suicide needs to take into account a number of interacting social factors that define our current New Zealand context: the continuing rise of elder abuse; the increasing social isolation of the elderly; a growth in the overall proportion of elderly; greater pressure on families to provide care; smaller and more fragmented families; an increasing tendency to see persons from a narrow functional perspective; and increasing economic pressures on our health system and families. As one commentator bluntly put it: "I oppose introducing euthanasia in a toxic climate."

The availability of state-sanctioned 'mercy killing' in this environment will, in the first instance, create additional pathways for abuse and neglect. There has never been a more dangerous time to introduce such laws.

There are also the threats that euthanasia/assisted-suicide would pose for quality end-of-life care, our trust in doctors, its potential impact on youth suicide prevention and the inevitable extension to children and to those incapable of giving consent. Further, in the current "toxic climate", a law change will reframe the way the sick, elderly and disabled see themselves and are seen by others. As an experienced nurse recently wrote: "Do assisted-suicide supporters really expect doctors and nurses to assist in the suicide of one patient, then go care for a similar patient who wants to live, without this having an effect on our ethics or empathy? Do they realise this reduces the second patient's will-to-live request to a mere personal whim — perhaps, ultimately, one that society will see as selfish and too costly?" In other words, hey realize that this reduces the second patient's will-to-live request to a mere personal whim—perhaps, ultimately, one that society will see as selfish and too costly? How does this serve optimal health care, let alone the integrity of doctors and nurses who have to face the fact that we helped other human beings kill themselves? expanding personal freedoms to include euthanasia or assisted-suicide undermines the right to remain alive without having to justify one's existence.

As overseas and New Zealand reports show, and contrary to popular opinion, the main reasons people favour euthanasia are not related to extreme physical pain (an experienced palliative-care physician reassures me that these days no-one need die in physical pain) but to such things as loss of autonomy [i], feelings of being a burden and dependency on others [ii], decreasing ability to participate in activities that made life enjoyable, fear of losing control, and social isolation [iii].

This knowledge is not at all contentious. Pro-euthanasia doctors such as Dr Rob Jonquiere openly recognise that many concerned elderly people will choose euthanasia or assisted suicide for such reasons. As Jonquiere noted in a 2013 presentation: "The elderly have feelings of detachment ... The elderly have feelings of isolation and loss of meaning. The elderly are tired of life ... Their days are experienced as useless repetitions. The elderly have become largely dependent on the help of others, they have no control over their personal situation and the direction of their lives. Loss of personal dignity appears in many instances to be the deciding factor for the conclusion that their lives are complete". [iv] In the same presentation, Jonquiere freely and readily admits that "the problem is not so much physical, but social and emotional ..."

What is particularly frightening and distressing, however, is the fact that Jonquiere's response to this is to advocate even more vociferously for these people to have the right to die. "The conclusion that life is completed is reserved exclusively for the concerned persons themselves ... They alone can reach the consideration whether or not the quality and value of their lives are diminished to such an extent that they prefer death over life." All of which leads him to the cold-hearted and brutal conclusion that it is "never for the state, society or any social system" [v] to question or otherwise interfere in such a person's decision.

Looked at through a lens of social justice and inclusion, Jonquiere's analysis and conclusion is deeply disturbing. The intolerable situation that increasing numbers of elderly people find themselves in might be a direct result of neglect, ageism, abuse, ignorance, lack of funding for services, poor public policies or, worst of all, a lack of will to care from family and/or society. But in Jonquiere's ideal society the most moral and caring thing to do is to not interfere with people's choice to kill themselves or be killed by a doctor! In effect, this means that the state, which governs over the society in which these persons live, the very same society that will in very many cases be complicit in their intolerable condition, can assuage its conscience by assisting these people to die.

This is not just. This is not the sort of society I care to live in. Rather than appealing to the best in people, rather than calling forth the sort of commitment and care that is quintessentially human, Jonquiere's 'solution' amounts, metaphorically, to a radical 'lowering of the bar' that sets the standards for inclusion in society.

It raises the spectre of a society in which elderly people's deepest needs, their need to overcome isolation, neglect and the ignominy of feeling a burden, will be ignored in favour of making it easy for them to dispose of themselves; their real needs papered over by appeals to the principles of autonomy and compassion which are morally vacuous because the choice to die would, for such people, be a choice made out of desperation, a choice made because of a lack of real choices, a tissue-thin choice that is ultimately the product of institutionalised familial and/or societal neglect.

This is precisely what Pope Francis was referring to when he recently commented that abandoning the elderly and disabled is itself a form of euthanasia. In fact, Jonquiere's response is just as much about abandoning the foundational principles of an ethical and caring society as it is about abandoning particular individuals.

We can do better than that! We must do better than that for the sake of future generations, our children and grandchildren who, for better or worse, will inherit the legacy of the choices we make. 'What sort of a world are we shaping for them?' is a key question not often asked.

Personal dignity and respect, as well as a commitment to equality and social justice, calls for nothing less than a whole-hearted active dedication to holistic care for those who are suffering, elderly or disabled. It will require a determined and focussed effort to ensure that what makes us distinctively human – our ability to show and receive care – is reflected in our personal and societal attitudes and familial, social, political and cultural structures.

True 'death with dignity' occurs when a person's deepest physical, emotional, social, cultural and spiritual needs are met, when a person feels loved and cared for and feels included and valued no matter what. It is, I accept, not the 'easy way out'. Neither is it for the faint hearted. At this point in our history, the call to care will demand from us great resourcefulness as well as sacrifice. But then, as life teaches us over and again, the easy way out rarely pays dividends.

We must be honest about the unintended, long-term, negative consequences of euthanasia and assisted-suicide for both individuals and society. There would be a huge social price to pay for legalising state-sanctioned killing, counted in lives prematurely ended because of a sad perception by persons that they were 'past their used by date' and had become 'useless eaters'.

Be careful what you wish for!

Dr John Kleinsman is a member of The Care Alliance and director of The Nathaniel Centre

 

Endnotes

[i] See, for example, Oregon Public Health Division – 2013 DWDA Report at http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year16.pdf

[ii] See, for example, Malpas, P, K Mitchell, and M Johnson. "'I Wouldn't Want to Become a Nuisance under Any Circumstances' - a Qualitative Study of the Reasons Some Healthy Older Individuals Support Medical Practices That Hasten Death." New Zealand Medical Journal 125, no. 1358 (2012): 9-19.

[iii] See, for example, Nicole Steck, Christoph Junker, Maud Maessen, Thomas Reisch, Marcel Zwahlen, Matthias Egger, and for the Swiss National Cohort "Suicide assisted by right-to-die associations: a population based cohort study". Int. J. Epidemiol. (2014) 43 (2): 614-622 first published online February 18, 2014. doi:10.1093/ije/dyu010

[iv] Jonquiere, R. Fourth Annual Lecture to the Society for Old Age Rational Suicide, London, September 20, 2013 http://www.soars.org.uk/index.php/pages

[v] Ibid.

Editorial: Euthanasia-on-demand and without demand – let’s not kid ourselves

Dr Rob Jonquiere, Communications Director of the World Federation of Right to Die Societies, has recently completed a tour of New Zealand at the invitation of the New Zealand Voluntary Euthanasia Society.

Dr Jonquiere supports the 'right to die' as a 'human right' and has argued that 'if you can choose what kind of house you're going to live in' why can you not choose what death?' In a lecture given in 2013 (Fourth Annual SOARS Lecture), Dr Jonquiere has outlined how the original pro-choice campaigners in The Netherlands wanted to argue for euthanasia on the grounds of 'self-determination' (that is, on the basis of unfettered personal choice and without needing to fulfil any particular conditions such as being terminally ill) – euthanasia-on-demand.

However, because it was deemed necessary for doctors to be involved in order to gain public acceptance, and because many doctors 'were not looking forward to assist in cases that did not fit within a medical domain', the campaign focus strategically shifted to advocating for a very select group - seriously ill patients. Having achieved this goal, however, the pro-euthanasia campaigners quickly modified their goals. The debate immediately turned to including 'demented human beings with an adequate advance directive; patients with a chronic psychiatric illness who had come to the end of meaningful treatment; and, elderly people who for a variety of reasons judged their lives completed.' [i]

Consequently, there has been a gradual widening of the categories of those eligible for euthanasia in The Netherlands and Belgium; it is no longer necessary for patients to be suffering a 'terminal' illness; psychiatric conditions including depression qualify, and the law in both countries now allows for children to be euthanised.

These changes are not evidence of a 'slippery slope' but are an inevitable consequence of the argument that it is a human right to be able to end one's life. If certain individuals have a 'human right' to make this choice, then it is irrational to restrict this right to only some people; it should apply to anyone who considers their life not worth living and who demands it.

The stated goal of 'euthanasia-on-demand' may well explain why, despite an outward insistence on effective legal safeguards, the practice of euthanasia in The Netherlands and Belgium routinely exists outside of the law. In Belgium, nearly half of all cases are not reported [ii] and in The Netherlands at least 20 percent of cases are unreported [iii] (reporting is mandatory by law in both countries). In unreported cases there is a higher likelihood that legal requirements are not met, such as the need for a written request (involuntary euthanasia), consultation with palliative care physicians, and a requirement that only physicians perform euthanasia. In Flanders, Belgium, in 2007, one study found 32 percent of physician-assisted deaths were without explicit patient request [iv]; another study noted drugs were administered by a nurse in 41 percent of unreported cases (none for reported cases) [v].

In light of the argument that individuals should have the right to decide how and when to end their lives, evidence that the law is not being followed, along with the widening of eligible categories, is not necessarily concerning for euthanasia advocates. Indeed, it is welcomed by those who support euthanasia as a 'human right', seen as an indication that the current situation is too restrictive and as a rationale that the law be further liberalised to reflect (what is now illegal) practice.

Anyone supporting 'voluntary' euthanasia and/or assisted suicide in New Zealand needs to accept that, within a short time, euthanasia will be demanded for children, those with dementia, depression and other mental illnesses as well as for those who are simply 'tired of life' as is happening overseas. Given that these groups include persons incapable of giving consent, it is inevitable that there will be a push to move beyond strictly 'voluntary' euthanasia despite the persistent denials of pro-euthanasia advocates.

In jurisdictions where euthanasia and physician-assisted suicide are already legalised, the move from voluntary to non-voluntary euthanasia has been a very small step. In the Netherlands it has always been the case that it is doctors who make the final decisions about end of life; patients can request it but doctors must ultimately decide. In other words, it is always the doctors who determine whether a person would be 'better off dead' [vi]. When doctors are already the ones judging whether a person would be 'better off dead', there seems little reason why they could or should not make this decision for comatose or incompetent patients without the need for 'informed consent'. Hence, the small step.

Apart from those who are immediately affected, there are wider social consequences, since introducing 'voluntary' euthanasia and physician-assisted suicide will do more than allow a small number of patients who are 'suffering unbearably' to be able to end their lives or have them ended. It will introduce into some of our most important institutions – the medical profession, the nursing profession, hospitals and rest homes – the 'ethic' that it is acceptable to kill, with or without consent; an ethic that will become socially embedded – the so-called 'normalisation' of state-sanctioned killing.

Such an 'ethic' is contrary to and will irrevocably harm these institutions and the human virtues that are most treasured in in our society.

 

Endnotes

[i] Fourth Annual SOARS Lecture (London, September 20, 2013). http://www.soars.org.uk/index.php/pages

[ii] Smets, T; Bilsen, J; Cohen, J; Rurup, ML; Mortier, F; Deliens, L. "Reporting of euthanasia in medical practice in Flanders, Belgium: cross sectional analysis of reported and unreported cases". BMJ 2010: 341:c5174.

[iii] Onwuteaka-Philipsen, BD; Brinkman-Stoppeleburg, A; Penning, C; de Jong-Krul, GJF; van Delden, M; van der Heide, A. "Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: a repeated cross-sectional survey". Lancet 2012; 380: 908-15.

[iv] Chambaere, K; Bilsen, J; Cohen, J; Onwuteaka-Philipsen, BD; Mortier, F; Deliens, L. "Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey". CMAJ 2010; 182:895-901.

[v] Smets et al. (2010) ibid.

[vi] Keown, J. "Mr Marty's muddle: a superficial and selective case for euthanasia in Europe". J Med Ethics 2006; 32:29-33.

Euthanasia – the bigger picture

Media generated discussions about euthanasia and assisted suicide are often initiated by the story of tragic individual cases. The rhetoric used invariably focuses on 'choice' and the so-called 'right' a person has to choose how and when they die. But this argument fails to recognise that people do not make their 'choices' in a vacuum, that such decisions inevitably involve and concern other people, not least the medical professionals and others who care for them and for others. The following select quotes highlight some of the bigger picture issues associated with legalising euthanasia or assisted suicide.

"The pro-euthanasia lobby talks enthusiastically about 'autonomy' and 'choice'. The truth is that when euthanasia is legalised, personal autonomy and choice are dangerously compromised. Moreover, legalising euthanasia - like capital punishment - has the power to brutalise society." Professor David Richmond.

"The killing decision in euthanasia and assisted suicide isn't really the suicidal person's 'choice': It is the killer's or helper's. In other words, life will end only if the joint venturer in the killing believes the suicidal person's life is not worth living." Wesley J. Smith.

"I've recently had quite a bit to do with one rest home village and I've had a chance to get the feel of the elderly residents and I know for a fact that if you had a voluntary euthanasia regime, the whole tone of that rest home village would be greatly altered as people came to fear the suggestion that they think might be made to them that they should seek euthanasia, that their time has come, that they've lived a long life, that they're being a burden to others, a very expensive burden in some cases, and that they'd be better off dead." Don Mathieson QC.

"Few people would seriously consider legalizing friend- or family-assisted suicide. The inherent dangers of this type of private killing are much too obvious. So the goal is to lend this act professional respectability by promoting physician-assisted suicide—or, more accurately, medically assisted suicide, since nurses also are necessarily involved when the assisted suicide occurs in a health facility or home-health situation.
As a nurse, I am willing to do anything for my patients—but I will not kill them nor help them kill themselves. In my work with the terminally ill, I have been struck by how rarely such people say anything like, "I want to end my life." I have seen the few who do express such thoughts become visibly relieved when their concerns and fears are addressed, instead of finding support for the suicide option. I have yet to see such a patient go on to commit suicide." Nancy Valko.

"The phrase 'death with dignity' is very often used to mean the deliberately procured death of an ill or disabled person, and strongly implies that vulnerable people are 'dignified' only in death.
I strongly believe that the supposed 'right to die' is a subterfuge for what is really a 'duty to die' because society prefers not to provide appropriate support to help us to live with dignity, but prefers the cheaper option of killing. Alison Davis, Disability Activist.

"Disability rights opposition [to legalising euthanasia] is based in reality. While Compassion & Choices and its media friends push policy on the back of one photogenic person's 'choice', we look at the social impact on vulnerable populations. The media repeats the falsehood that there have been no abuses in Oregon, we present evidence that shows the opposite ... When the focus is on an individual, assisted suicide can sound good -- who's against compassion or relieving suffering? But a closer look reveals that assisted suicide puts vulnerable people in mortal danger. The more people learn about the real-world implications of these bills, the more they oppose them. (Our group takes its name -- Second Thoughts -- from this fact)." John B Kelly, Disability Activist

"[The pro-euthanasia] slogan is people should be allowed to die with dignity, which suggests that they don't. I've seen hundreds of people die... it's just part and parcel of your life as chaplain and I would say in the time that I've been chaplain, which is about 35 years, I don't think I can remember a case where people didn't die with dignity." Rev David Orange

"Do assisted suicide supporters really expect us doctors and nurses to be able to assist the suicide of one patient, then go on to care for a similar patient who wants to live, without this having an effect on our ethics or our empathy? Do they realize that this reduces the second patient's will-to-live request to a mere personal whim—perhaps, ultimately, one that society will see as selfish and too costly? How does this serve optimal health care, let alone the integrity of doctors and nurses who have to face the fact that we helped other human beings kill themselves?" Nancy Valko.

Book Review: Five Days at Memorial

Kilian de Lacy

FIVE DAYS AT MEMORIAL BY Sheri Fink
(Atlantic Books Ltd, London, 2013)

This Pulitzer Prize winning book attempts, in over 500 pages, to give as accurate an account as possible of the devastating effect of Hurricane Katrina on New Orleans in August 2005, and in particular of events during and after the crisis, when medical professionals were arrested and accused of having hastened the death of some of their patients.
The prologue paints a dramatic picture of the scene within the hospital when some patients were being evacuated, and the horrendous choices which loomed in the consciences of the dedicated medical staff who had stayed at the hospital to care for their seriously ill patients.
The first chapter gives an overview of previous similar, though less devastating, natural events which should have made authorities aware of what they needed to do in preparation for future natural disasters and from which, as is painfully evident in the ensuing chapters, they had failed to learn, with tragic results.
The author, Sheri Fink, has been the recipient of several journalism awards and was a former relief worker in disaster and conflict zones, so her personal experience of such events is considerable. She conducted hundreds of interviews with doctors, nurses, family members, staff and others involved. She visited the hospital and other sites depicted in the book, and made use of source materials dating from the time of the disaster and its immediate aftermath. All in all, her research was thorough and extensive.
The style of writing is conversational and this brings to life the many characters who played lead roles in the disaster, especially those faced with the prospect of having to help dangerously ill patients who had been placed on Category 3 lists for evacuation, i.e. those who were to be taken out last or, more likely under the circumstances, not at all.
The disaster is painted in all its dreadful detail, the recurring theme being the lack of preparedness of the authorities to deal with the crisis. For instance, despite prior experience of flooding in the basement of the hospital, the power generators were still there, making it inevitable that the power went off as the water from the breached levees in the city flooded the lower parts of the building. Efforts to provide respirators, to keep patients comfortable and cool when the air conditioning failed, to preserve life and hygiene were maintained under increasingly challenging conditions. The inconsistency of communication between those on the ground and authorities elsewhere made painful reading.
Then there were the people: the medical staff, the patients, the families of the patients, the people who had sought refuge from the flood in the hospital, many bringing their pets along with them and expecting the animals to be rescued even before patients. Prominent among the medical staff were Dr Anna Pou and nurses Cheri Landry and Lori Budo, later to be charged with second-degree murder for intentionally killing four of the patients at Memorial Hospital.
When the floods receded, 45 bodies were found at Memorial Hospital, more than in any other rest home or hospital in the city. Nine patients, all in the Life Care unit and seriously ill, had died under suspicious circumstances. All nine had unusual amounts of morphine in their systems, some in combination with sedative drugs.
The book makes gripping reading. The author's detailed research is evident and the reader is drawn into the moral dilemmas which had beset those doctors and nurses charged with the care of these patients. It poses the questions:
• If you were caring for seriously ill patients without any of the normal backup systems a hospital offers and knowing that some authority had decreed that the most debilitated patients were to be evacuated last, if at all, what would you do?
• Is it ever permissible to administer to such patients a drug which may cause their death but would prevent their dying in agony and distress because of the lack of life support or other fundamental medical resources?
• Who was responsible for altering the triage priority for evacuation from sickest first (which is normal practice) to sickest last?
As the story moves into the post-Katrina phase of investigation, arrests, media exposure, accusations and legal proceedings, we are given a fascinating picture of the background agendas behind the moves against the three medics and the ever-intriguing play of American politics.
This is a book which will challenge those who think that euthanasia is only a black and white issue. Many of the leading characters implicated in the administration of allegedly lethal doses of morphine are Catholics working out of a moral tradition that holds to the maxim always to cure, not kill. At the same time, by highlighting the influence of systemic failure, the book also carries a warning to those in authority who fail to learn from history and are therefore doomed to repeat it. I strongly recommend it.

Kilian de Lacy is a writer and a nurse (now retired) who specialised in the care of the elderly and the dying. She continues to work with the elderly and other vulnerable individuals through her involvement in Grey Power and Agape Budgeting Services. She is an active member of Holy Family Parish, Porirua.

Death as a Penalty: A Moral, Practical, and Theological Discussion

Pope Francis has recently called for the abolition of the death penalty, as well as life imprisonment which he has described as a hidden death sentence. The following article provides a discussion of some of the theological issues that have led to a shift in Catholic thinking about capital punishment.

Peter Hung Tran

Introduction

‘Capital punishment’ or ‘the death penalty’ is a subject of much controversy in modern times.  The authority of the State to administer a death penalty for horrendous crimes against the common good of persons and society has traditionally enjoyed support from biblical and theological resources in the Christian community. Such support is not without criticism, and contemporary ecclesial reflection on this question raises important moral issues. This paper critically examines the justifications for the death penalty and the arguments against its endorsement. These arguments are looked at in the light of biblical perspectives and from the teaching of the Catholic Church.

Some people advocate for capital punishment because it helps protect the innocent from criminals while others believe it can reduce crime rates1 by deterring criminals from acting unlawfully.  However, most people disapprove of capital punishment2, seeing it as just another form of murder and a moral disgrace.3 

Those who believe capital punishment to be an efficient way of discouraging murder often point to the old Bible teaching: "it shall be life for a life, eye for an eye, tooth for a tooth." (Deut 19:21). Within that framework, the argument for capital punishment can be formulated thus: some acts are so evil and so destructive of community that they invalidate the right of the perpetrator to membership and even to life. This is what St. Thomas Aquinas argued. He contended that it is legitimate to kill dangerous criminals as a way of upholding the common good.4 

The Christian theological tradition has likewise supported the administration of the capital punishment in the form of the following arguments:

1.            The authoritative power of the state is affirmed in the New Testament (Rm. 13:1-4),5  and the state is empowered to act on behalf of the common good of the society. When the common good is threatened, particularly when human life is directly assaulted, the state must take appropriate measures to defend the lives of innocent citizens. Such protection may require the execution of the lawless.

2.            Capital punishment serves as a deterrent and contributes to the preservation of public order.

3.            Capital punishment is an exercise in judgment and not hatred. To quote Pope Innocent III: "We assert, concerning the power of the State, that it is able to exercise a judgment of blood, without mortal sin, provided it proceed to inflict the punishment not in hate, but in judgment; not incautiously, but after consideration" (Anti-Waldensian Profession, DS, no. 795).

Perhaps the most compelling argument against capital punishment can be made on the basis of society’s ability to administer it:  There is always a possibility of error; an innocent person could be put to death; capital punishment is also demonstrably unfairly administered; statistics show that it is inflicted disproportionately on the poor and minorities.6 The claim that the threat of capital punishment reduces violent crime is also found to be inconclusive. 7 Meanwhile,  others believe that it is unfair to hold criminals fully accountable for their wrongdoing; persons who commit crimes have often suffered from neglect, emotional trauma, violence, cruelty, abandonment, lack of love, and a host of destructive social conditions.         

More recently, there seems to be a growing tendency in both church and society to restrict the use of death penalty to very limited circumstances or even to abolish it completely. 8 In his homily in St. Louis of Jan. 27, 1999, Pope John Paul II said,

"A sign of hope is the increasing recognition that the dignity of human life must never be taken away, even in the case of someone who has done great evil. Modern society has the means of protecting itself without definitively denying criminals the chance to reform. I renew the appeal for a consensus to end the death penalty, which is both cruel and unnecessary."9

In a similar vein, Pope Francis in his recent speech to the representatives of the International Association of Penal Law, on 23 October 2014, also called for the abolition of the death penalty:

“It is impossible to imagine that states today cannot make use of another means than capital punishment to defend peoples' lives from an unjust aggressor.”

He reiterated the primacy of the life and dignity of the human person, reaffirming the absolute condemnation of the death penalty, the use of which is rejected by Christians.10 

Although he noted, “According to the Catechism of the Catholic Church, the traditional teaching of the church does not exclude recourse to the death penalty, if this is the only possible way of effectively defending human lives against the unjust aggressor, but modern advances in protecting society from dangerous criminals mean that cases in which the execution of the offender is an absolute necessity are very rare, if not practically nonexistent”.11

In line with this, certain contemporary theologians have argued for the elimination of the death penalty for the following reasons:

1.            The death penalty is useless and unnecessary. The incidence of violent crime does not appear to be appreciably lessened by the retention of capital punishment. An alternative is to deter the offender by means of lengthy imprisonment.

2.            The death penalty dehumanises society by legitimating violence as a strategy to deal with human wrongdoing. The current climate of violence reflects a genuine lack of social justice and solidarity, which remains unaddressed by recourse to capital punishment as a means to deter crime.

3.            The death penalty does not reflect the consistent biblical trajectory of forgiveness, hope, and redemption. In the Sermon on the Mount Jesus instructs his disciples to seek no revenge for wrongdoing. 12

A Biblical Perspective

Supporters of the death penalty frequently cite the Old Testament to justify their position.13 In Genesis 9:6 we read: "If anyone sheds the blood of man, by man shall his blood be shed; for in the image of God has man been made." Any person who murders another is to be killed. The blood of the victim murdered defiles the land. The only way it is cleansed is by administering capital punishment to the murderer (Num. 35:33-34). Then, when God gave the law to Moses, additional offences were considered capital crimes.14 

At the same time, Mosaic law and the later rabbinical tradition established a strict set of judicial procedures for cases involving the death penalty. The standard of proof required to convict someone in such cases went beyond our standard of "beyond reasonable doubt" and required what amounted to absolute certainty. A conviction required at least two eye witnesses (Numbers 35:30) before someone accused of murder could be put to death, and witnesses who lied subjected themselves to the same penalty as the accused (e.g. Deut. 17 and 19). In practice Hebrew law became more restrictive which meant fewer people were convicted. More restrictions were added later so that by the second century the death penalty was rarely carried out.15 

In the New Testament, Jesus' answer to capital punishment was to undermine the penalty by demanding that both judges and executioners be sinless. "Let anyone among you who is without sin be the first to throw a stone at her." He reminds his listeners to be careful of condemning others because God's judgments do not necessarily coincide with our own (e.g. Matthew 25, Luke 6). If our judgments are so fallible, how can we make the decision to take a life? In addition, Jesus' pardoning of the woman caught in adultery (a civil offence requiring capital punishment) is an example of his mercy. In this way Jesus challenges the presumption that humans can ever authorize the death penalty as judge and /or executioner. 16

In addition, the New Testament emphasises that the sacrificial aspect of taking a life was fulfilled "once and for all" by the sacrifice of Christ.17  Christ's death on the cross, itself an application of capital punishment, wiped away the Old Testament ceremonial and moral basis for the death penalty (e.g. Hebrews 10).18  No more blood needs to be shed to testify to the sacredness of life. Christ has died so that others may live.

Jesus also constantly reiterated our responsibility to see Christ in our needy neighbor, even in our enemies; we are told to love and forgive those who harm us. When Christ was executed, he gave a model response to his enemies in his dying words: "Father, forgive them." By doing that Jesus replaces the law of retribution with the law of reconciliation (Mt 5:23-4). He also teaches that we are to love those who harm us, “I say to you, love your enemies and pray for those who persecute you, so that you may be children of your Father in heaven" (Matthew 5:43-45).

Reflection and Conclusion

The biblical perspective on the death penalty is of relevance to our society and raises a series of critical questions: If the death penalty does not actually further the effort to maintain order, if indeed it may actually interfere with good order, is the State using its authority appropriately? When the State punishes arbitrarily and discriminatorily, especially with a penalty so final, is it properly carrying out its God-given role?

Jesus teaches that life belongs to God and is not ours to take. We should repudiate capital punishment because it is incompatible with the basic focus of the Gospel - reconciliation and redemption. Christ's concern is redemptive, and he has provided us a model by giving himself for his enemies. We must give the opportunity for redemption to every sinner, without exception, even for a murderer who failed to do that for his or her victim. Jesus did not die only for certain sinners, he died for all. To either deprive a person of the possibility of reconciling themselves to God and humanity or to end the life of someone who has reconciled is the real tragedy of capital punishment.

Finally, debates about the death penalty all too easily sidetrack us from deeper issues: the causes of violence and its meaning for both victim and offender. Before we can find answers to these, we need to reach within ourselves. We must realise that each of us has suffered, that we are all in some sense victims. But we also need to identify the roots of violence and injustice that are in us all. We need to acknowledge our own complicity and failure, that we have all sinned and fallen short of what we could and should be.  So, we are all offenders and we are all victims; we all need redemption. It is only in realising this that we can build a future where violence will be unnecessary.

“Is the human family made more complete, is human personhood made more loving, in a society which demands life for life, eye for eye, tooth for tooth?” (Cardinal Joseph Bernardin).   

Rev Dr Peter Hung Tran STD, is a Catholic Moral Theologian and Bioethicist. He works at the L.J. Goody Bioethics Centre in Western Australia and is a sessional lecturer at the University of Notre Dame, Australia and Good Shepherd College, New Zealand.

Endnotes

1. See R. Michael Dunnigan, JD, JCL., “The Purposes of Punishment.” Source:http://www.catholicculture.org/culture/library/view.cfm?recnum=7453 (accessed 06.10.2012).

2. The death penalty is outlawed in most of Europe, Canada, Australia, and most other countries in the world; more than 135 nations have abolished capital punishment. “The death penalty: A flawed system we can't afford to keep.” Published By Times Herald. Posted: 07 Oct, 2012. Source: http://www.timesheraldonline.com/opinion/ci_21719050/death-penalty-flawed-system-we-cant-afford-keep (accessed 08.10.2012).

3.  See “A Good Friday Appeal to End the Death Penalty.” By the United States Conference of Catholic Bishops, April 2, 1999. Source: http://old.usccb.org/sdwp/national/criminal/appeal.shtml (accessed 07.10.2012).

4. Thomas Aquinas,   Summa theologiae  II-II, q. 64, a.2.

5. While some argue that St. Paul affirms the right of governing authorities to punish offenders (see John Berkman and Stanley Hauerwas, "Capital Punishment," in Paul Barry Clarke and Linzey (eds.) Dictionary of Ethics, Theology and Society.  (New York: Routledge: 1996), 102),  this view has been rejected by Jean Lasserre: "No Christian justification of the death penalty can be deduced from Roman 13, so there is no single text in the New Testament which approves it." Cited by Peter Black, "Do Circumstances Ever Justify Capital Punishment?" Theological Studies 60(1999), 342-3.

6. John Langan "Capital Punishment,"Theological Studies, 54(1993),114.

7. See Jewish-Catholic Consultation, "To End the Death Penalty," Origin 29 (1999), 463; and also John Berkman and Stanley Hauerwas, "Capital Punishment," in Paul Barry Clarke and Linzey (eds.) Dictionary of Ethics, Theology and Society.  (New York: Routledge: 1996),p.103.

8. John Paul II,  Evangelium vitae, nos. 53-57; John Paul II's homily Jan. 27, 1999, in St. Louis, MO; U.S. Catholic Conference, "Statement on Capital Punishment," Origins 10 (1980), 373-77; The "Good Friday Appeal to End the Death Penalty" issued by the Administrative Board of the U.S. Catholic Conference on April 2, 1999; Catholic Bishops' Conference of the Philippines, "Restoring the Death Penalty: A Backward Step," Catholic International 3 (1992), 886-888; John Langan, "Capital Punishment," Theological Studies 54 (1993), 111-24; Significantly was the joined statement between Jewish-Catholic Consultation, "To End the Death Penalty," Origin 29 (1999), 463-4.

9. Jewish-Catholic Consultation, "To End the Death Penalty," Origin 29 (1999), 463.

10. See Pope Francis calls for abolishing death penalty and life imprisonment. By Francis X. Rocca,  Catholic News Service. Published on 23 October 2014 . http://www.catholicnews.com/data/stories/cns/1404377.htm  (accessed 28 Oct. 2014) and also Pope to Association of Penal Law: Corruption is Greater Evil than Sin. By Vatican News - 23 October 2014.  http://www.news.va/en/news/pope-to-association-of-penal-law-corruption-is-gre  (accessed 28 October 2014).

11. Ibid.

12. John Berkman and Stanley Hauerwas, "Capital Punishment," in Paul Barry Clarke and Linzey (eds.) Dictionary of Ethics, Theology and Society.  (New York: Routledge: 1996), pp.100-105.

13. Yet it is important to keep in mind that the New Testament must be the primary standard for Christians.

14. In the Law of Moses fifteen different crimes were singled out for the death penalty including hitting your parents (Ex. 21:15); Kidnapping (Ex. 21:16); Killing an unborn infant (Ex 21:22-25); Adultery (Lev. 20:10); Incest (Lev. 20:11-12 & 14); Rape under some circumstances (Deut. 22:25). It should be noted that from Noah until the institution of the Law, the Bible only sanctioned capital punishment for murder. See John Berkman and Stanley Hauerwas, "Capital Punishment," in Paul Barry Clarke and Linzey (eds.) Dictionary of Ethics, Theology and Society.  (New York: Routledge: 1996), 102.

15. Jeremiah J. McCarthy, "Capital Punishment," in Judith A. Dwyer, (ed.)  The New Dictionary of Catholic Social Thought. (Collegeville, Minnesota: The Liturgical Press, 1994), 109-111, at 109

16. God alone is the author of life, therefore only God has the dominion of life, says the National Jewish-Catholic Consultation in a Dec. 6, 1999, report - Origins 29 (1999), 463; Similarly, John Berkman and Stanley Hauerwas, in the same way, would claim it also, "all life, guilty or not, belongs to God and is to be given and taken only by God." (p. 104)

17. John Berkman and Stanley Hauerwas,  Ibid.

18. John Berkman and Stanley Hauerwas, "Capital Punishment," in Paul Barry Clarke and Linzey (eds.) Dictionary of Ethics, Theology and Society.  (New York: Routledge: 1996), p.102.

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