Samaritanus Bonus: On the care of persons in the critical and terminal phases of life

Bp Gerald John Mathias
12 Oct 2020

The Vatican Congregation for the Doctrine of the Faith (CDF) issued a Letter Samaritanus Bonus (The Good Samaritan) on July 14, 2020, the Memorial of St. Camillus de Lellis, and it was made public on September 22, 2020. Following the example of the Good Samaritan, who is Jesus Christ himself, the CDF addresses the very sensitive issue of care of persons in the critical and terminal phases of life, with special reference to the moral issues involved in euthanasia and assisted suicide. Basically, the present Letter “seeks to enlighten pastors and the faithful regarding their questions and uncertainties about medical care, and their spiritual and pastoral obligations to the sick in the critical and terminal stages of life.”

The Letter intends to “reaffirm the message of the Gospel and its expression in the basic doctrinal statements of the Magisterium” and “provide precise and concrete pastoral guidelines to deal with these complex situations at the local level and to handle them in a way that fosters the patient’s personal encounter with the merciful love of God.”

The 25-page (foolscap) document quotes profusely (99 footnotes) from earlier documents of the Church and has five main headings, apart from Introduction and Conclusion, to deal with the following topics: i) Care for one’s neighbour; ii) the living experience of the suffering Christ and the proclamation of hope; iii) human life is a sacred and inviolable gift; iv) the cultural obstacles that obscure the sacred value of every human life; and v) the Teaching of the Magisterium.

I. Care for one’s Neighbour

The Letter acknowledges that suffering always raises limitless questions about the meaning of life. However, the pressing questions cannot be answered solely by human reflection but also need the light of Revelation of God. Caring for the other is what we learn from the Good Samaritan. The Good Samaritan “not only draws nearer to the man he finds half dead; he takes responsibility for him.” Thus, “we need to show care for all life and for the life of everyone.” 

Care for life is therefore the first responsibility that guides individuals like physician, nurse, relative, volunteer and pastor in the encounter with the sick, especially at the critical and terminal stages of life. Therefore, they should “adhere to the highest standards of self-respect and respect for others by embracing, safeguarding and promoting human life until natural death,” and treating the sick with dignity

However, we must accept death as part of human condition. “One cannot think of physical life as something to preserve at all costs – which is impossible – but as something to live in the free acceptance of the meaning of bodily existence.” Nonetheless, when cure is not possible and death is imminent, it does not entail the cessation of medical and nursing activity. Care must be provided until the very end: “to cure if possible, always to care.” Additionally, true care involves “not merely physical, but also psychological, social, familial and religious or spiritual support to the sick.”

II. The Living Experience of the Suffering Christ and Proclamation of Hope

Christ’s experience on the Cross resonates with the sick, who are often seen as a burden. In the Cross of Christ are concentrated all the sickness and suffering of the world: physical, psychological, moral and spiritual. The Cross of Christ gives meaning to most of human suffering. Just like Mary remaining at the foot of the Cross, the family and care-givers remaining at the bedside of the sick gives great emotional and spiritual support. 

III. Human Life is a Sacred and Inviolable Gift

Samaritanus Bonus reaffirms the Church’s perennial teaching that human life is a sacred and inviolable gift. “Whatever their physical or psychological condition, human persons always retain their original dignity as created in the image of God.” Furthermore, it rightly affirms: “Life is the first good because it is the basis for the enjoyment of every other good including the transcendent vocation to share the trinitarian love of the living God to which every human being is called.” 

Respect for human life implies that we protect and safeguard life and do not destroy it. “Just as we cannot make another person our slave, even if they ask to be, so we cannot directly choose to take the life of another, even if they request it. Therefore, to end the life of a sick person who requests euthanasia is by no means to acknowledge and respect their autonomy, but on the contrary to disavow the value of both their freedom… and of their life. Moreover, it is to take the place of God in deciding the moment of death.” The decision about the moment of death is God’s prerogative, not ours. 

For this reason, reaffirming the teaching of Gaudium et Spes the present Letter states clearly: “abortion, euthanasia and willful self-destruction…poison human society, but they do more harm to those who practice them than those who suffer from injury. Moreover, they are a supreme dishonour to the Creator.” (G.S. 27)

IV. The Cultural Obstacles that Obscure the Sacred Value of Every Human Life

The Letter of CDF goes on to enumerate few cultural obstacles that obscure the sacred value of human life in modern society. The first obstacle lies in the notion of “dignified death” as measured by the standard of the ‘quality of life,’ which is often seen in terms of economic means, well-being, beauty and enjoyment of physical life, forgetting the other, etc. According to this view, “a life whose quality seems poor does not deserve to continue. Human life is then no longer recognized as a value in itself.”

The second obstacle is a false understanding of “compassion.” In the face of seemingly “unbearable” suffering, the termination of a patient’s life is justified in the name of compassion. This so-called “compassionate” euthanasia, commonly referred to as mercy-killing, holds that it is better to die than suffer and that it is an act of compassion to help a patient die by means of euthanasia or assisted suicide. But in reality, as the Letter points out “human compassion consists not in causing death, but in embracing the sick, in supporting them in their difficulties, in offering them affection, attention, and the means to alleviate their suffering.” 
The third factor is a growing individualism, where the other is viewed as a limitation or a threat to one’s freedom. “Individualism, in particular, is at the root of what is regarded as the most hidden malady of our time: solitude or privacy.” 

V. The Teaching of the Magisterium

Samaritanus Bonus then goes on to reaffirm the Teaching of the Magisterium under 12 important points .A brief explanation on each of these important points is in order.

1) The prohibition of euthanasia and assisted suicide: Church has a divine mandate to uphold natural moral law and is obliged to avoid any ambiguity in its teaching. In the face of legalized euthanasia, assisted suicide and protocols such as Do Not Resuscitate Order, living wills, etc. healthcare workers, patients and their relatives have serious problems in making proper decisions. “The Church is convinced of the necessity to reaffirm as definitive teaching that euthanasia is a crime against human life because, in this act, one chooses directly to cause the death of another innocent human being (for it is) an action or an omission which of itself or by intention causes death, in order that all pain may in this way be eliminated.” Euthanasia is, therefore, an intrinsically evil act in every situation or circumstance.
.”When a request for euthanasia rises from anguish and despair, “although in these cases the guilt of the individual may be reduced, or completely absent, nevertheless the error of judgement into which the conscience falls, perhaps in good faith, does not change the nature of this act of killing, which will always be in itself something to be rejected.”

Enactment of laws which legalize euthanasia and assisted suicide is gravely unjust and a degradation of legal systems, affirms the CDF Letter. 

In this context we need to remember, and experience confirms that “the pleas of gravely ill people who sometimes ask for death are not to be understood as implying a true desire for euthanasia; in fact, it is almost always a case of an anguished plea for help and love When a sick person gets this love, warmth and spiritual support, he/she can overcome all forms of depression and despair. 

2) The moral obligation to exclude aggressive medical treatment : While human life is to be respected and protected, we must accept death as part of the human condition. The dignity of the human person entails the right to die with the greatest possible serenity and with one’s human and Christian dignity intact. Hence, to precipitate death or delay it through “aggressive medical treatment” deprives death of its due dignity. With medical and technological advancements today, death can be artificially delayed, often without real benefit to the patient. “When death is imminent, and without interruption of the normal care the patient requires in such cases, it is lawful according to science and conscience to renounce treatments that provide only a precarious or painful extension of life.”

3) Basic Care: the requirement of nutrition and hydration: While extraordinary treatment can legitimately be suspended, ordinary care, such as hydration and nutrition, cannot be suspended. “A fundamental and inescapable principle of the assistance of the critically or terminally ill person is the continuity of care for the essential physiological functions… Obligatory nutrition and hydration can at times be administered artificially, provided that it does not cause harm or intolerable suffering to the patient.” 

4) Palliative Care: The CDF underscores the need of palliative care for terminally ill patients. “As demonstrated by vast clinical experience, palliative medicine constitutes a precious and crucial instrument in the care of patients during the most painful, agonising, chronic and terminal stages of illness. Palliative care is an authentic expression of the human and Christian activity of providing care.”

Palliative care should include spiritual assistance for patients and their families. However, it does not include the possibility of requesting euthanasia and assisted suicide. It would be morally unlawful to include such a provision in palliative care.

5) The role of the family and hospice: The Letter underscores the role of the family as central to the care of the patient. It is essential that the sick do not feel themselves to be a burden, but can sense the intimacy and support of their loved ones. 

Next to the family, hospice centres which welcome the sick and ensure their care provide an important and valuable service. These centres are an example of genuine humanity in society. 

6) Accompaniment and care in prenatal and paediatric medicine: Children need care just like adults. “Beginning at conception, children suffering from malformation or other pathologies are little patients whom medicine today can always assist and accompany in a manner respectful of life. Their life is sacred, unique, unrepeatable and inviolable, exactly like that of every adult person.”

“The empathetic accompaniment of a child, who is among the most frail, in the terminal stages of life, aims to give life to the years of a child and not years to the child’s life.” Today’s dominant culture, unfriendly to disability, often prompts the choice of abortion portraying it as a kind of “prevention.” Abortion is the deliberate killing of an innocent human life, and as such it is never lawful.

7) Analgesic therapy and loss of consciousness: To mitigate a patient’s pain, analgesic therapy employs drugs that can induce sedation. The Church “affirms the moral liceity of sedation as part of patient care in order to ensure that the end of life arrives with the greatest possible peace and the best internal conditions.” However, the use of analgesics that “directly and intentionally causes death is a euthanistic practice and is unacceptable. The sedation must exclude, as its direct purpose, the intention to kill, even though it may accelerate the inevitable onset of death.”

8) The vegetative state and the state of minimal consciousness: Many terminally ill patients lie for long in a persistent vegetative state (PVS) or state of minimal consciousness. CDF Letter warns: “It is always completely false to assume that the vegetative state, and the state of minimal consciousness, in subjects who can breathe autonomously, are signs that the patient has ceased to be a human person with all of the dignity belonging to persons as such… One must never forget in such painful situations that the patient in these states has the right to nutrition and hydration, even administered by artificial methods… In some cases, such measures can become disproportionate, because their administration is ineffective, or involves procedures that create an excessive burden with negative results that exceed any benefits to the patient.” Only then they may be withdrawn.

9) Conscientious objections on the part of healthcare workers and Catholic healthcare institutions: Healthcare workers must exclude any formal or immediate material cooperation in euthanasia or assisted suicide or any immoral practice. “It is never morally lawful to collaborate with such immoral actions or to imply collusion in word, action or omission.” In such situations, “we must obey God rather than men” (Acts 5:29). 
Healthcare workers as well as Christian healthcare institutions have a right to conscientious objection and in fact have a moral obligation to refrain from co-operation in immoral acts. And governments must acknowledge this right. 

10) Pastoral accompaniment and the support of the Sacraments: Death is a decisive moment in the human person’s encounter with God the Saviour. The Church is called to accompany spiritually the faithful in this situation. No believer should die in loneliness and neglect. The last Sacraments provide great comfort, consolation and spiritual strength to the patient.

The parable of the Good Samaritan shows the qualities to be avoided and those to be embraced in such accompaniment. While indifference, apathy, bias, fear of soiling one’s hands and self-obsession are the qualities to be avoided, attention, listening, understanding, compassion and discretion are the ones to be adopted. 

11) Pastoral discernment towards those who request euthanasia or assisted suicide: Pastoral accompaniment of those who expressly ask for euthanasia or assisted suicide today presents a singular moment for the pastor to reaffirm the teaching of the Church. For valid and worthy reception of Sacraments of Penance, Anointing and Viaticum, the confessor must discern the penitent’s readiness to take concrete steps that indicate he or she has modified the decision in this regard. Thus a person who may be registered in an association to receive euthanasia or assisted suicide must manifest the intention of cancelling such a registration before receiving the sacraments.

Those who assist these persons spiritually must avoid any gesture, such as remaining until the euthanasia is performed, that could be interpreted as approval of this action, and so avoid scandal.  

12) The reform of the education and formation of the healthcare workers;Education has a critical role to play in rightly forming the healthcare workers. Families, schools, other educational institutions and parochial communities must reawaken and refine the sensitivity of people towards their sick and suffering neighbours. More importance is to be given to palliative care. 

Conclusion:

Given the dominant ‘throw-away culture’ and ‘culture of death’ in the world, where abortions, euthanasia and assisted suicide are legalised and are responsible for the deaths of millions, a presentation of the clear teachings of the Church was timely and necessary. Though abortion is only mentioned in passing since it was not the purpose of this Letter, euthanasia and assisted suicide get sufficient attention in the context of pastoral care of terminally ill. The CDF has through this Letter clarified many issues that cause confusion in the minds of pastors, faithful, healthcare workers, etc. Though moral judgement on these issues remains unchanged, the pastoral approach provided is truly of the Good Samaritan, who is Jesus Christ himself. Due emphasis is laid on the necessity of medical, physical, psychological, familial, social and spiritual support to the sick in general and terminally ill in particular. May “every individual feel as if called personally to bear witness to love in suffering.” Let us be compassionate persons, Good Samaritans, who bring love and hope in the face of death. 


(Bp Gerald John Mathias is the Bishop of Lucknow, UP)

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