Is Choosing to Die Sometimes Morally Permissible and Spiritually Defensible?

Is Choosing to Die Sometimes Morally Permissible and Spiritually Defensible?
By Mike Attas and Robert Baird

   Michael, under hospice care, had lung cancer that had metastasized to his brain. Suffering also with shingles, he was in agony. Physicians and hospice personnel struggled to find a pain control regimen that would provide him some relief and, thus, some quality of life. The pain medications included morphine, Thorazine, Elavil, decadron, and ibuprofin. An increase in back pain led to the discovery of an infection of the vertebrae, requiring surgery that left the spinal column and vertebrae exposed from the shoulder blades to the waist. The irrigation of his wound and the changing of the dressing were agonizing. During the eight days after surgery, his condition deteriorated and the morphine was increased from 40 mg. per hour to 255 mg. per hour. “Even with massive doses of morphine and valium he did not experience comfort.”¹ To choose to die in such circumstances can be both morally permissible and spiritually defensible. Indeed, requiring individuals to live under such circumstances against their will actively injures them by forcing their continued existence.²

   She sits in an alcove at the end of the hall wholly unaware of her environment. Every morning attendants lift her from bed and tie her into a comfortable chair with soft pieces of cloth. During the day, she hangs there; they tend to her bodily needs, including feeding her by putting food in her mouth and massaging her throat, helping her to swallow. In the evening, they replace her in bed.  With ongoing care, she could continue to exist in this manner for years.³ To choose in advance to die in such circumstances can be both morally permissible and spiritually defensible.

   While the thesis of this paper is that choosing to die is sometimes acceptable, morally and spiritually, this essay has a sub-text relating to the process of moral decision-making. That sub-text will be addressed first; its relevance to the essay’s basic claim will become clear.  

    We speak in a variety of ways about our moral beliefs. We say, “I have a strong intuition or feeling or moral conviction that a course of action is right or wrong.” We speak of conscience as our guide, as in “my conscience is leading me to do this or telling me to do that.” For most of us, these are simply ways, sometimes metaphorical, of asserting our moral judgment, of stating what we think we ought to do or what is permissible to do. It is our (Attas and Baird) feeling, our conviction, our moral intuition, our judgment that choosing to die under certain circumstances is morally permissible and spiritually defensible.

   The problem, of course, is that one’s moral intuitions and feelings can be mistaken. One’s conscience can mislead. Moral judgments may be wrong. In the face of this fact, the proper option is the way of philosophy: thinking hard about one’s intuitions and judgments and considering reasons for and against them. “I am,” said Socrates, “one who must be guided by reason.”⁴ Contemporary philosophers, too, are “professionally wedded to reasoning.”⁵

   We are, then, doing philosophy. We are not simply expressing our opinion. We are attempting to reason clearly about what we think is morally permissible and spiritually defensible. We are expressing a considered judgment, one that has been sustained after reflection and discussion.  No guarantees, of course. Even after careful thought, one can be wrong. Moral decision-making is risky business.

   Evidence that it is risky is that thoughtful people of good faith continue to differ about moral matters. Consider the United States invasion of Iraq in 2003 and our current military involvement in Afghanistan; consider same-sex marriage, capital punishment, or abortion. Why is moral agreement hard to come by? There are explanatons why the giving of reasons does not always resolve disagreements. The philosopher John Rawls refers to what he calls the burdens of judgment: the reasons why agreement in moral matters is difficult.⁶ The evidence for competing views is often complex and conflicting. Even when there is agreement on the evidence, individuals may weigh various pieces of evidence differently. Moreover, this process of weighing evidence, interpreting data, and making judgments is influenced by past experiences that vary with each individual who, to a significant extent, is a product of his or her history. Finally, even when there is absolute agreement on moral principles, individuals have to make tough judgments about the application of principles in particular situations. Moral agreement even among reasonable persons is, thus, hard to come by.

   A student at the end of an ethics course expressed disappointment in the class. “I thought,” he said, “that if I took a course in ethics, I would come out with a set of principles or standards that would tell me precisely what to do in any situation I faced.” In effect, he wanted a definitive moral calculator. He wanted a set of principles that would relieve him of moral decision-making, relieve him of making particular moral judgments. That we cannot be so relieved is both the glory and the anguish of being human. The glory is the creative satisfaction that comes with responsible decision-making. The anguish is the inevitable presence of moral disagreements.

   And there is certainly disagreement regarding the morality of choosing to die, particularly when that choosing moves beyond passively letting nature take its course. Physician-assisted death is among the most controversial moral disagreements in this country, though a recent Gallup Poll (2017) shows a strong majority of Americans (73%) support physician-assisted death.⁷ 

And physicians, too, are increasingly supportive. “Fifty-seven percent of physicians believe physician-assisted death should be available to terminally ill patients, up from 54% in 2014 and 46% in 2010 . . . .”⁸  Moreover, “a growing number of medical societies, such as the California Medical Society, have dropped their opposition to physician-assisted death and have adopted a neutral position.”⁹  

   In a recent piece in the New York Times, “Should I help My Patients Die?” palliative care specialist Dr. Jessica Zitter discusses some of the complicated issues surrounding the question of assisted death and her discomfort with the idea. Nevertheless, she admits:

I want this option available to me and my family. I have seen much suffering around death.  In my experience, most of the pain can be managed by expert care teams focusing on symptom management and family support. But not all. My mother is profoundly claustrophobic. I can imagine her terror if she were to develop Lou Gehrig’s disease, which progressively immobilizes patients while their cognitive faculties remain largely intact. For my mother this would be a fate worse than death.¹⁰

   While physician-assisted death, she concludes, should be “a tool of last resort, medical aid in dying is the law in my home state [California] and I am glad for that.” ¹¹

   Some opponents of physician-assisted death, however, characterize the position we will defend in strong language, seeing it as an evil—a mischievous and dangerous¹² folly¹³. Defenders of the choice to die are often described as being caught up in a “Culture of Death” by those who attempt to grab the rhetorical and moral high ground by identifying themselves with the “Culture of Life.” As the Gallup Poll makes clear, however, a majority now supports choosing to die under certain circumstances. We should add further that many Christians support such a choice, again, under certain circumstances. Indeed, a preeminent American theologian and philosopher, John Cobb, Professor Emeritus, Claremont School of Theology, argues that the Christian Church should repent of its opposition to those who would choose to die under certain conditions.¹⁴ After considering opposing arguments and rethinking ours, our conviction remains that choosing death in certain circumstances is morally permissible and spiritually defensible.  

        By the phrase “choosing to die,” we mean: (1) the intentional termination of life, (2) by an act of omission or commission, (3) by the choice of the one who dies (a) because he or she is experiencing physical distress and emotional suffering that rob life, from his or her perspective, of the possibility of positive meaning, or (b) because he or she is no longer capable of conscious life. (In this case, of course, the choice would have been made in advance.)

   Choosing to die by an act of omission involves refusing treatment when to do so will likely result in death sooner rather than later. Examples include rejecting a respirator, refusing chemotherapy, or foregoing penicillin. This form of choosing to die is not particularly controversial. Most individuals and religious traditions agree: At times, it is legitimate to cease medical intervention even though to do so means dying sooner than one otherwise would.  At times, it is morally permissible to choose to die sooner rather than later by rejecting medical intervention.

   The thesis we are advancing, however, is stronger than this; for we are defending choosing to die under certain circumstances by an act of commission, that is, directly causing death by giving an individual an injection or by providing medication that the person assumes responsibility for taking. Such an action is legal in some countries (the Netherlands, Belgium, Germany, Canada, Switzerland and Japan) and in six states in this country (Oregon, Washington, Montana, Colorado, California and Vermont) and in Washington D.C.  The difference between the practices in the Netherlands and Belgium, on the one hand, and the other countries listed and the states in this country, on the other, is the difference between active euthanasia and physician-assisted death. In active euthanasia, the physician administers the lethal injection. In physician-assisted death, the physician provides the means of dying which the patient then pursues on his or her own.

   We will defend the moral permissibility of both of these practices, always with the proviso of carefully worked out procedures and guidelines. We will advance two arguments—the first has to do with moral permissibility, the second with spiritual defensibility.

   The first argument is rooted in the value of individual agency and responsibility. This value was cogently expressed in the 1992 Supreme Court Decision, Planned Parenthood of Southeastern Pennsylvania v. Casey: “matters involving the most intimate and personal choices a person may make in a lifetime, choices central to personal dignity and autonomy, are central to the liberty protected by the Fourteenth Amendment.”¹⁵Again, says Casey, “at the heart of liberty is the right to define one’s own concept of existence, of meaning, of the universe, and of the mystery of human life.”¹⁶ The essence of this claim is that, apart from one’s family and other communities of one’s choosing, the larger society is not justified, at least in some circumstances, in deciding such an issue for the individual. What some have called a zone of privacy should prevail here.

     Valuing individual agency need not involve a failure to recognize and to value the communal nature of life.  Indeed, life itself is a gift of community, of a community of two, which immediately becomes a community of more than two, and eventually a community of many. Moreover, decisions we make, particularly momentous decisions, have consequences for the various communities of which we are a part. Any decision for death, then, should be, to some extent, a communal one.

   Neither is valuing individual agency to be confused with absolutizing autonomy or making a fetish of individual freedom. Frequently, those who value individual agency are accused of putting an excessive and obsessive emphasis on autonomy, on individual choice and self-determination. That criticism cuts both ways: Some put excessive and obsessive emphasis on social control.  In fact, the issue is not individual freedom or community. It is freedom within the midst of a community that recognizes the value of individual agency; for without individual agency and freedom there can be no moral accountability.

    We indicated earlier that making moral judgments is both the glory and the anguish of being human.  Making such judgments is the glory of being human because it focuses our capacity for conceiving of ends and goals and purposes in life, and the freedom to exercise that capacity is among the greatest of human goods.  Such freedom gives “substance to the concept of liberty.”¹⁷   We are responsible for the course of our lives; that is what is meant by human agency.

   Since dying is an inevitable aspect of life, should we not feel an obligation, to the extent possible, to assume some responsibility for that too?  Concern with how we die is a further manifestation of concern with who we want to be, with how we want to be remembered.  It is as if we were painting the picture of, or writing the story of our lives, and concern with our manner of dying is concern for the final details of the portrait or the final chapter of the story.  This becomes critical when we are faced with becoming a person incompatible with the values we cherish or incompatible with how we want to be remembered by those we love.  Does not our right as agents involve the right to preclude this from happening?  Do we not as moral agents have the right to paint the final stroke or to write the last line?  Some goods are more important than mere biological existence.

   Of course, the idea of making choices—including the decision to end one’s life—in keeping with the values we cherish is complicated by the fact that we are committed to a whole host of values and some of our own commitments may be in tension. The value of agency and self-determination may lead in one direction, while valuing the voice of one’s community may lead in another. To repeat an earlier emphasis, there is no escaping judgment.

   We also recognize that for many, their values preclude assisted death under any circumstances.  Moreover, we do appreciate the unavoidability of and the value of undergoing suffering in the course of human life. John Wilcox, in his perceptive book, The Bitterness of Job: A Philosophical Reading, correctly and valuably notes that

            living is more than acting.  To live is to act; but it is also to undergo, to experience, to suffer, to be a patient….  My life is, in part, a matter of whether I rob my neighbor…[or] help him in time of need…of things I do; but…[life] is also a matter of becoming sick, of growing old, of being injured…of dying—not things I do…but things I undergo…. ¹⁸

   Wilcox reminds us that at times being a responsible patient requires that one live with sickness, that one accept the debilitation of old age, that one accept injury, or that one passively undergo death. Some may affirm this in a way that precludes assisted death. (We do not know Wilcox’s position on this matter.) We want to affirm much of what Wilcox affirms, but we do not think, in the last analysis, that it counts against the moral permissibility of choosing death under certain circumstances.

   One of the strongest objections to the agency or self-determination defense is the claim that it is self-contradictory or self-defeating. Choosing to die, argues Leon Kass, is not affirming autonomy. It permanently destroys autonomy; it takes away forever the ability to make choices.¹⁹ Michael Gill’s response to Kass is persuasive, however. With proper guidelines, physician-assisted death can be restricted to those for whom death is imminent (as do the legal guidelines in all of the states that permit physician-assisted death), restricted to those for whom agency and autonomy will end soon, or has already ended (as illustrated by the case described in the second paragraph of this essay). As Gill puts it:

The person with a terminal illness who decides to commit suicide is not changing the universe from a place in which she would have been able to exercise her autonomy in the future into a place in which she will not be able to exercise her autonomy in the future. For she will not be able to exercise her autonomy in the future no matter what she does. Hers is not a decision to prevent herself from being able to make future decisions, because future decisions will not be hers to make regardless. The ending of her decision-making ability is a foregone conclusion. She is simply choosing that it end in one way rather than another. The person who commits suicide [given certain preconditions for the legalization of such an act] should be compared to someone who blows out a candle that has used up all its wax and is now nothing but a sputtering wick that is just about to go out on its own. She should not be compared to someone who snuffs out the bright, strong flame of a new candle.²⁰

     Now to the second of the two arguments we are advancing in defense of assisted-death under certain circumstances, the claim that such an action can be spiritually defensible. ²¹

   Religious communities have, by and large, opposed active euthanasia and physician-assisted death. This opposition is expressed in several formal statements: a Jewish document: "only He who gives life may take it away;"²² a Baptist formulation: "We believe life and death belong in the hands of God;”²³an Episcopal statement: the "Church believes that as God gives life so only through the operation of the laws of nature can life rightly be taken from human beings;"²⁴ and Pope John Paul II’s affirmation: “God alone has the power over life and death.”²⁵ These statements have been referenced in particular because they express the religious reason for the opposition so directly; a recent study by the Pew Foundation reaffirms this typical religious objection to assisted death.²⁶

   The argument is straightforward.  God is the giver of life; therefore, only God has the right to take it.  When we intervene in the time of death, we usurp divine prerogative.  This has been and continues to be the fundamental religious argument against active euthanasia and physician-assisted death.

   We want to respond to this objection by suggesting a religious perspective for thinking about human responsibility that might reorient our view on who has responsibility for death. The framework we propose takes its key from the weakness in the traditional religious objection that since God is the giver of life, only God has the right to take it.

   One might readily grant that the premise of this argument is true in one sense, but there is also a sense in which it is false. Anyone who views God as creator, as the author of natural processes, will view God is the source of life. But those processes have been designed to include human beings as necessary to the production of human life. Both God, then, as the foundation of natural processes and human beings as the agents of reproduction are necessary conditions for the creation of human life. Moreover, scientific advances in medicine enable us to make human life possible in circumstances where previously it was impossible. Humans, then, are necessary for the creation of life, and, at times, necessary for the sustaining of life.

   To be created in the image of God is understood in a variety of ways. A widely held interpretation is that we, too, are endowed with the ability and freedom to create. We have accepted this power regarding the creation and sustaining of life.  Is it not time to assume it with regard to death? "Only he who gives life may take it" is the traditional religious argument against choosing when to die. But does not the fact that God has assigned us a role in the creation (the giving) and sustaining of life suggest the possibility that God may, at times, be assigning us a role in the taking of life?

   Old Testament scholar Barry Bandstra has suggested that “the image of God is something we have as well as something we do.”²⁷ The idea is that we have authority and dominion over the created order that leads to a responsibility for action. That is an awesome responsibility. Clearly God has given us authority and dominion and responsibility for the creation of and sustaining of life. Is the authority to create a human life and to sustain it any less awesome than the authority to ease another into death when that other has judged his or her life to have reached its creative end? We accept responsibility for the creation and sustaining of life. Why not also for a comforting death?

   When we think of the natural order that God has created, an order that includes tsunamis, earthquakes and hurricanes that can in an instant dispatch human lives by the thousands—when we think of this natural order, it seems clear that God has allocated incredible responsibility to humans for coping with the cards we are dealt. The point is: God no more tightly controls death by “an act of pure (and) singular divine agency” than he “controls the creation of life through pure (and singular) divine agency.”²⁸ We readily recognize human responsibility for the beginning of life; we should acknowledge the extent to which we already assume much responsibility for the continuation of life and for when life ends.  

   A fundamental religious model within the Judeo/Christian tradition is the image of God as father or parent.  Consider parents’ relationships with their children. Thoughtful parents raise children to assume increasing responsibility for their own decisions. They help them become mature by increasing their accountability. Evidence that children have become adults is their ability to assume responsibility for the profound choices that affect their lives and the lives of others.

   What about the divine parent? Does it not appear that God is using time itself²⁹ and the evolutionary process to increase the responsibility of his children? Does that not seem to be God's plan for human development—increasing our responsibility even for (especially for) matters of life and death? In attempting to understand how God relates to the created order, understanding the evolutionary process must play a key role. Human beings have evolved over time in a variety of ways—biologically, socially, religiously and technologically. Notably, what have evolved are human capacities, and the physician/philosopher Tristram Engelhardt is surely correct: "the expansion of human capabilities has resulted in an expansion of human responsibilities . . . .”³⁰

   The pediatrician in the hospital nursery assumes responsibility for life when she places the prematurely-born in the incubator. A member of a medical emergency team assumes responsibility for life when he resuscitates a heart attack victim. The surgeon assumes responsibility for life every time she removes a perforated appendix. We have long since passed the "watershed of medical innocence."³¹ That has been inevitable in the evolutionary process.

   To paraphrase the 18th century philosopher, David Hume: If it is God’s role to decide when we shall live and when we shall die, then we play God just as much when we cure people as we would do by helping them to die.³² Isn’t assuming something of a god-like role and taking responsibility part of what it means to say that we have been created in the image of God?  In fact, evolution seems to have prepared us to interfere increasingly with natural processes by “making things happen that otherwise would not have happened, or preventing things from happening that otherwise would have happened.”³³ As the philosopher Simon Blackburn notes: As a critical objection, “the charge of playing God has no independent force.”³⁴ The only time people raise this objection is when the interference occurring is something to which they object.³⁵ In ways we all approve, we play God by assuming responsibility for creating life, and we increasingly assume god-like responsibility for life by mending it when it is broken. Is it less human, less religious, to assume, at times, responsibility for death?   

   The Christian tradition rejects biological idolatry.  This has relevance for the Christian view of a successfully completed life. We admonish ourselves and others to be in the world, but not of it.  Even a non-religious person can be sympathetic with this admonition. Life alone, simple biological existence, is not the highest value. Altering slightly the observation of another: if “life is not an absolute good to be preserved” under any circumstances, neither is death “an absolute evil to be avoided at all costs."³⁶

   When illness, accident or the ravages of time take away one’s understanding of the meaningfulness of life or take away irrevocably that which makes one a person, is not the absolute determination to keep the body functioning a form of biological idolatry at odds with the religious spirit? Can the assumption of responsibility under certain circumstances (the proviso “under certain circumstances” always understood) for deciding that it is time to die not, then, be considered a role divinely given?

   David Thomasma, writing from within the Catholic tradition, understands the “breathtakingly” difficult issues involved in the assisted-death question, and his pacifism causes him to be cautious about such assistance. Nevertheless, he concludes “that it is a brutality to the sacredness of human life to extend it unduly,” that “to wish to say ‘no’ . . . may be a grace given by God,” and that “to help [someone die] may be an act of faith in the invisible hand of God.”³⁷ In fact, several people have indicated to us that they could envision such a moment as sacramental.  We, too, have often thought that under certain circumstances, the gathering of one’s family, friends, spiritual mentor, and physician for the purpose of easing one into death can be a sacred moment in which others become the hands of God.  We envision it as a spiritual occasion in which gratitude is expressed for what has been and for what continues, in memory, to be, and a spiritual gathering in which hope is expressed for what yet may be.

     A few caveats: We have witnessed the remarkable role hospice can play at times in easing an individual into death without assisted death or euthanasia. Indeed, the broad-based support in this country for the right to choose death under certain circumstances has probably served as an impetus for the hospice movement and as an impetus for developments in palliative care at the end of life. This is all to the good.

   Furthermore, we have much appreciation for the work of our colleague, philosopher Kay Toombs and her thoughtful writings on disability. In her reflections on how to define disability, on what it means to experience disability, and on how society responds to the disabled, we have been reminded of the extent to which attitudes in society toward caring for others influences our thinking about issues such as choosing death.³⁸ We certainly agree that deep and pervasive social attitudes toward caring need exploration and, perhaps, alteration, and that these matters are directly relevant to debates about physician-assisted death. Such issues are, in fact, the focus of Dr. Atul Gawande’s widely read and reviewed 2014 book Being Mortal. He acknowledges, however, that “suffering at the end of life is sometimes unavoidable and unbearable, and helping people end their misery may be necessary.” He adds:  “Given the opportunity, I would support laws to provide [prescriptions to hasten the timing of their death].”  It is important to emphasize, however, that Gawande acknowledges this in the context of emphasizing that we should not permit dependence on providing the means of hastening death to keep us from developing palliative care programs that would reduce the call for such hastening, that would reduce the call for physician-assisted death.³⁹

   And there are additional issues with which we have not dealt—issues requiring ongoing serious conversation. Life is complex, and death makes it more so. Moreover, we fallible creatures see through a glass darkly. But for every thing there is a season, and a time for every purpose under heaven: a time to be born, and a time to die. At times, death is good. At times, bringing it about may be both morally acceptable and spiritually defensible.

   Since the issue we are discussing is such a personal and sensitive one, we have decided to conclude with this physician’s personal reflection. I remember both the first and last time I disconnected a respirator and stayed at the bedside while my patient quietly expired. In 45 years of clinical medicine, it never got any easier. I never quit asking myself if it was the “right” thing to do. It never quit hurting. Yet, despite the soul-searching and the pathos and the tears, at the end of the day, it always felt like I had acted in my patients’ best interests. I felt that I had lived, albeit painfully, into the fullness of my vocational calling. I have performed that act hundreds of times in futile and painfully hopeless conditions. And given the complexity of what it means to be a “healer” in the truest sense of the word, at the end of the day, I felt that I had lived into the true, raw, honest depth of the human condition as it intersects the practice of modern medicine.

   I have read, both with wonder as well as frustration, academic and theological arguments for and against physician-assisted suicide. I understand the need to parse, explain and justify a given position. And certainly this paper explains in detail why my colleague and I take the faith-based arguments seriously within our mutually shared Christian tradition. I fully understand and respect the need to place the arguments within a given religious persuasion; for that is where many of us live and place the ground of our daily lives and commitments. And while I understand the academic differential between ‘active’ and ‘passive’ physician-assisted death, at the end of the day, I would submit that ontologically they are one and the same. They are acts that begin in the prefrontal cortex and cognitive areas of the brain. They excite certain neurotransmitters to action. A limb moves. A finger pushes a button or a plunger. And a human being dies. Those are the anatomic and physiological facts. To say that one is “morally acceptable” and thus, legal, and another is somehow “immoral” and illegal is to miss the point. We live, like it or not, in an imperfect world where doctors do their best on behalf of patients. We often do that quite well; yet, as we all know, we may miss the mark and make errors of both commission and omission. Being human—that also is our destiny and our fate. It comes with the territory. We can’t pass it on to ethics committees or legislatures that often have hidden or political agendas. We are called to act on behalf of our patients, often even when we do not “know” their expressed wishes. And to compound that difficulty, even families may differ on the best course of action.

   When I was teaching undergraduate medical ethics, I often asked the simple question: Why do you want to go into medicine? The answers varied of course: to  help people; to cure cancer; to do mission work; to heal the sick; to love; to make lots of money; because my parents wanted me to. A rare student would answer: to relieve human suffering. Not once did I ever hear “to prolong life at all costs”. Yet that answer is the presumed underpinning of laws that do not honor the fact that we all are finite creatures. That naïve perspective drives legislative policy in modern society when at no point within a 3000-year history of medicine has that been a declared or even implicit goal. I believe that, at the end of the day, suffering in terminal illnesses can be not only meaningless but may actually detract from our full humanity. The notion that suffering is a part of “soul making” often falls to shreds at the bedside.  My colleague and I believe that at times the most loving, compassionate, Christian, and yes, healing thing we can do is to act on behalf of patients by allowing and, at times, assisting them to die peacefully. We can assist them with grace and dignity and respect for their uniqueness and humanity and for their “imago Dei.” And when we do that with compassion and love, then I think we live fully into the concept of healer.

Mike Attas is a retired cardiologist, Professor of Medical Humanities, Baylor University, and an Episcopal priest

Robert Baird is Professor Emeritus of Philosophy, Baylor University

Notes

¹Margaret Wolters, “Personal Narratives,” Choosing Death: Active Euthanasia, Religion, and the Public Debate, ed. Ron Hamel (Philadelphia: Trinity Press International, 1991), 9.

²H. Tristram Engelhardt, Jr. "Ethical Issues in Aiding the Death of Young Children," included in Robert Baird and Stuart Rosenbaum (eds.), Euthanasia: The Moral Issues (Buffalo, New York: Prometheus Books, 1989).  In this essay, Engelhardt introduces “the concept of the ‘injury of continued existence’,”142.

³Personally observed by Baird.

⁴Plato, “Crito,” The Dialogues of Plato, trans. B. Jowett, vol. one (New York: Random House, 1937), 430.

⁵Simon Blackburn, Being Good (Oxford: Oxford University Press, 2001), 109

⁶John Rawls, Political Liberalism (New York: Columbia University Press, 1993), 54-58.

⁷Jade Wood and Justin McCarthy, “Majority of Americans Remain Supportive of Euthanasia,” Gallup Poll, May 3-7, 2017.  Politics, June 12, 2017.  Online.  The approval numbers are up 4 points in the last year.  See the immediately preceding Gallup Poll: Dave Andruske, Gallup’s Latest Poll on Euthanasia and ‘Doctor-Assisted Suicide’.” National Right to Live News Today, June 30, 2016.

⁸Robert Lowes, “Assisted Death: Physician Support Continues to Grow,” Medscape, Medical News (Online), December 29, 2016.

⁹Ibid.

¹⁰Jessica Nutik Zitter, “Should I Help My Patients Die?” New York Times Sunday Review, August 6, 2017, 4.

¹¹Ibid.

¹²CF Daniel Callahan, “The Sanctity of Life Seduced: A Symposium on Medical Ethics,” First Things, 42 (April 1994), 13.

¹³CF Leon Kass, Life Liberty and the Defense of Dignity (San Francisco: Encounter Books, 2002), 231 and 255.

¹⁴John B. Cobb, Jr., Matters of Life and Death (Louisville, KY: Westminster/John Knox Press, 1991), 68.

[1]⁵“Planned Parenthood of Southeastern Pennsylvania v. Case,” reprinted in The Ethics of Abortion, edited by Robert M. Baird and Stuart E. Rosenbaum, 3^rd ed. (Amherst, New York: Prometheus Press, 2001), 95.

¹⁶Ibid. 95-96.

[1]⁷CF Charles Fried, Right and Wrong (Cambridge: Harvard University Press, 1978), 147.

[1]⁸John T. Wilcox, The Bitterness of Job: A Philosophical Reading (Ann Arbor: The University of Michigan Press, 1989), 50.

¹⁹Kass, Life, Liberty, and the Defense of Liberty, 217.

²⁰Michael Gill, “A Moral Defense of Oregon’s Physician-Assisted Suicide Law,” Mortality, February 2005, 10 (1), 55-56.

²¹This is an expanded version of an argument appearing in an earlier essay appearing in this journal.  Robert M. Baird, “Is There a Right to Die?” Christian Ethics Today, February 1997, 24-28.

²²Ron Hamel and Edwin Dubose, “Views of the Major Faith Traditions,” Choosing Death: Active Euthanasia, Religion, and the Public Debate, 56.

23Ibid. 65.

24Ibid. 69.

25The Gospel of Life (New York: Random House, 1995), 121.

²⁶See “Religious Groups’ Views on End-of-Life Issues,” Pew Research Center: Religion and Public Life (Online), November 21, 2013.

27Barry Bandstra, Reading the Old Testament, 3^rd ed. (Belmont, CA: Wadsworth, 2004), 62.

²⁸Scott Bader-Sayer, professor of Christian ethics and moral theology at the Seminary of the Southwest (Episcopal) in Austin, Texas, made this point in correspondence with co-author Attas. 

29Cf. Michael Hanby’s “time is itself the vehicle for the revelation of the eternal.” “The Culture of Death, The Ontology of Boredom, and the Resistance of Joy,” Communio, 31 (Summer 2004), 198

30Engelhardt, Jr. "Ethical Issues in Aiding the Death of Young Children," 148.

31Joseph Edelheit, “Is Active Euthanasia Justifiable? A Reflection,” Choosing Death: Active Euthanasia, Religion, and the Public Debate, 108.

32David Hume, “Of Suicide,” Essays: Moral, Political, and Literary, ed. Eugene F. Miller (Indianapolis: Liberty Classics, 1987), 583.

33Simon Blackburn, Being Good (Oxford: Oxford University Press, 2001), 58.

34Ibid.

35Ibid.

36Margaret Murphy, "Should We Have A Public Policy: Reflection," Choosing Death: Active Euthanasia, Religion, and the Public Debate, 122

37David C. Thomasma, “Assisted Death and Martyrdom,” Christian Bioethics, Vol. 4, No. 2, 1998, p. 139.

38See for example Kay Toombs, “Living and Dying With Dignity: Reflections on Lived Experience,” Journal of Palliative Care, Vol. 20, No. 3 (2004), 193-200.

³⁹ Being Mortal: Medicine and What Matters in the End (New York: Metropolitan Books, 2014), 244-245.

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