As states continue to pass legislation legalizing physician-assisted suicide (PAS), it becomes ever more pressing to get to the heart of what is driving this movement. We have seen in surveys from the early adopter states some of the main reasons the terminally ill seek out PAS prescriptions. This is included in a variety of publications and will not be examined in depth in this paper. I wish to focus on three underlying forces that unfortunately fuel society's drive towards the suicide solution.

Then I will examine our faith community's response, seeking out areas for further development. I hope that this article will continue the conversation regarding the ways the church and its members can assist those who are near the end of the earthly journey.

AUTONOMY
Autonomy in our society usually upholds one's independence and freedom to choose. We see this understanding being used by politicians and media activists who promote PAS legislation. An editorial by the New York Times in September 2015 urged Governor Brown to sign the California End of Life Option Act. In this article, the editorial board praised the ability of taking "control of the timing of [one's] death." This line sounds familiar to the mission of the pro-PAS organization Compassion and Choices, which seeks to "increase patient control" and "access to all end- of-life options."¹ Control and access, power and options — these are the values promoters of these bills argue for and that have resonated in our society.

A major critique of this autonomy approach emerges when outsiders question whether PAS in fact promotes these desired outcomes. Cathleen Kaveny's use of political philosopher Joseph Raz's version of autonomy calls into question the desired effect of these laws. She rightly picks up the cry of most PAS supporters that these laws provide more autonomy for the terminally ill. However, she shows the ways that death with dignity legislation actually decreases a person's autonomy. The inclusion of PAS as part and parcel of patient treatment choice could lead to the underdevelopment of other treatments, especially palliative care or hospice services: "The change in law might abate the urgency of providing other forms of end-of-life assistance."² It also inherently places a value judgment on those who choose to die naturally, or in this debate, "without dignity." All of this could lead a person to choose death prematurely, therefore, undermining the state's interest in protecting the vulnerable from coercion or manipulation. With autonomy as a rallying cry for pro-PAS activists, it is mandatory that any plan of action to counter PAS legislation address this concern.

THE FAMILY
Autonomy and family go hand in hand in this debate. David McCarthy speaks about the economic forces affecting the modern family and the way in which society puts a high value on the independence of the family unit: "Rather than household management or filial duties, modern families have political and market relations at their center."³ The wage earner is the spokesperson for the family since it is this individual who is the provider. The economic character of the family defines its relationship to society. Therefore, a family that does not seek welfare assistance and can contribute to the market is valued and upheld as an exemplary model. McCarthy even dives into the current family structure to show that children must also have a level of independence, learning "the standards of conduct," and contributing to the betterment of the family itself.⁴

These observations on the family reveal another layer of unconscious support for PAS at the end of life. Terminally ill patients already fear being a burden to their family. However, families themselves may desire to avoid being a burden to society, and therefore, decide to keep the situation internal. I believe that this could lead them to find solutions that would require the least assistance from the greater community, avoiding costly alternative options. Asking for financial support for hospice or long-term palliative care would reveal a weakness in the autonomous and independent family unit valued in contemporary society.

Lisa Cahill recognizes this dilemma as a failure of social justice for all, which especially affects poor communities. She observes: "The health care situation for disadvantaged populations is worsened by poverty and constraints on resources in the community as a whole; for individuals, it can also be exacerbated by communal expectation that the welfare of one should give way to the needs of the family."⁵ This communal expectation is similar to the personal autonomy situation, where the need to ask for help, even from one's family, is seen as a loss of independence — loss that is undesirable.

CHRISTIAN DUTY TOWARDS BURDEN
The Catholic tradition has tended to place a high value on bearing suffering for others. The obvious example is that of Christ who, according to some Christologies, took upon himself the sins of the world. In one way, Jesus' example can be viewed as a person who conscientiously chose to suffer rather than take the "easy" way out. However, in a more inherent way, Jesus reveals the model of alleviating others' pain through personal suffering, through personal choice. By extension, it is possible that dying patients could then find value in making the decision to end their lives deliberately, as if this would eliminate the burden on their family members. "I will choose when to end my life, so my family does not have to."

We can see this idea borne out in Catholic writings on motherhood and the expectations of a dutiful wife. JoAnne Marie Terrell, for instance, writes a chapter titled, "Our Mothers' Gardens." In it she describes the way that certain Christologies have sadly fueled the continued oppression of black women in America. She concludes her reflections on the power of this tradition by relaying the story of her mother:

Although I may never be required to give up my life for the sake of my ultimate claims, the peculiar efficacy of my mother's sacrifice as well as the Christian story prevent me from discarding the idea altogether, particularly the notion of sacrifice as the surrender or destruction of something prized or desirable for the sake of something with a higher claim …⁶

These models of virtue indirectly promote the idea that women in particular ought to sacrifice their own bodies and dreams for the betterment of the family. Could then the church's upholding of such behavior promote the ultimate sacrifice of a terminally ill patient for the sake of their family? Could these Christian models actually increase Christian willingness to actively embrace and pursue a kind of martyrdom?

SOLUTIONS
Ars Moriendi
Many theologians draw upon the tradition of ars moriendi to address the social promotion of PAS legislation. One such author is Christopher Vogt, who devotes an entire book to the subject. In it, Vogt highlights certain virtues in the tradition that one must develop in their lives in order to face death in a correctly Christian way. He sees a strong connection between ars moriendi (the art of dying) and ars vivendi (the art of living). Vogt writes, "It is by a lifelong effort to nurture faith, hope, patience, compassion, and all the virtues of the good Christian life that we best prepare ourselves for the time of dying."⁷

This pairing of the two "arts" stems from the teaching of virtue ethics. Virtue ethics promotes the idea that all actions have a shaping effect on the actor's character. Therefore, virtuous actions create a virtuous person, sinful actions create a sinful person. To become a virtuous person "it is necessary to engage consciously in practices that concretize the good in order to … move oneself closer to embracing the good life."⁸

Vogt and the tradition understand that to help people face death they must have the virtues of hope, compassion, and patience.⁹ These three virtues provide the individual the proper inherent disposition to see death not as mere suffering, but as a part of our Christian journey. It is a personal development that hopefully will reap rewards at the end of our days.

Cathleen Kaveny offers a similar solution. She draws upon an exemplar of a good Christian death — Cardinal Joseph Bernardin — to reveal to the world the power of faith and an alternate approach to death. Using his last book, The Gifts of Peace, in which the Cardinal reflects on his diagnosis, treatment, remission, and then the return of cancer, Kaveny wants to show a truly Christian manner of dying. She argues that Cardinal Bernardin's example can serve as a "framework [that] can facilitate the exercise of Razian autonomy on the part of dying patients, and solidarity on the part of those surrounding them."¹⁰ Cardinal Bernardin chose to see his death as another leg of the trip, extending "beyond mortal existence to eternal life."¹¹

He chose to treat his life as a steward whose "ultimate nature and purpose are determined not by [himself] but by the creator … "¹² This gave him true freedom: "the freedom to let go."¹³

The manner in which he chose to accept his final years allowed Bernardin the ability to overcome his suffering by staying true to his life's mission as pastor. The writing of his personal story gave him the opportunity to recognize the power he still had in providing positive change in another person's life. This is the example of a more truly "autonomous" individual who reintegrated his torn self and gained a new narrative. It is a call for all of us to reflect not only on the life we wish to live, but also the death we wish to experience.

Falling Short
Even though I as a Christian find these arguments very convincing for my own life and I will take the lessons they teach into my personal vocation, I do not believe they address all the underlying problems. Kaveny's use of Cardinal Bernardin rightly, and I believe successfully, counters the pro-PAS conversation on autonomy and death-with-dignity. The example reveals a more Christian and, hopefully, a better definition for autonomy. The story also urges the onlooker to witness a dignified death that did not utilize PAS, therefore undermining the very title of these laws. Good as such outcomes are, they do not go far enough to redress the deeper, socio-structural problems that make PAS seem like a fitting solution to the challenge of dying well.

Similarly, Vogt's use of ars moriendi also addresses the autonomy and dignity debates. However, like Kaveny, he does not recognize the power of social structures to force people to end their own lives. Furthermore, this tradition can also be used to justify the third underlying force mentioned above – Christian duty towards burden. Ars moriendi is a very personal experience; one must shape their own dispositions in order to have the strength needed to face their death. It places a great burden on the individual and some may deny its appeal, as if the "art of dying" is synonymous with telling them just to bear it. For example, Vogt includes a passage from William Perkins, an ars moriendi thinker:

He that would be able to beare the crosse of all crosses, namely death itselfe, must first of all learne to beare small crosses, as sicknesses in body & troubles in mind, with losses of goods and of friends, of good name, which I may fitely tearme little deaths . . . wee must first of all acquaint our selues with these little deaths before we can well be able to beare the great death of all.¹⁴

Even though Vogt goes on to counter this passage with a more updated definition of patience, it nevertheless is a quote from an original ars moriendi writer. The idea that a good Christian will bear the "great death" by bearing a succession of small deaths makes it seem saintly to face hardships alone. This passage does not value asking for help or seeking someone to lean on. It does not ask society to change health services and financing. It is a theme that undergirds the tradition, and unfortunately, is one that may prevent people from using palliative and hospice services.

FINDING ANSWERS IN THE COMMUNITY
When we take seriously the concerns of the patients along with the underlying forces promoting PAS, we realize our solutions must be broader. Personal fortitude at death can only lead us so far. To overcome the pressures on family and the inability to humbly ask for help, social views on weakness and burden must be dramatically changed. The authors under review do have some insights with which to start such a process of revision, especially Kaveny's defense of solidarity and Vogt's promotion of compassion.

Kaveny addresses the desire of supporters to create an option that would alleviate one's suffering. She draws from the work of Eric Cassell. Suffering is for Cassell "'the distress brought about by the actual or perceived impending threat to the integrity or continued existence of the whole person.'"¹⁵ Again, she places this conception within the Razian definition of autonomy. Kaveny writes, "In Raz's terms, then, suffering is such a wrenching experience because it disintegrates previously autonomous persons, cleaving them from the plans and purposes with which they have defined themselves as part-authors of their own lives."¹⁶

Where does this lead us? If we hold a Razian sense for autonomy, and we believe that suffering is something which diminishes a person's autonomy, then we must find "a way forward toward reintegration, toward a new life that somehow also incorporates a narrative about the old life."¹⁷ We must give people the ability, the opportunity at least, to regain personal identity and mission. Using the writing of Bernardin, Kaveny puts it this way: "We are called to be one another's keepers and to bear one another's burdens as brothers and sisters in Christ."¹⁸ We are called to live in solidarity. "By standing with those who suffer, we can potentially help them to reconstruct their identities, find a new wholeness in their lives, and ultimately transcend the loss of their previous integrity."¹⁹

Kaveny then redirects our focus to the fundamental questions in this debate, namely: "What constitutes a good life in this community, what constitutes a good way to take one's leave from life, and what our collective obligations are to those in the midst of their leave-taking."20 These are questions that a community must answer, not only an individual. It requires strong, but productive debate and a great deal of reflection.

Christopher Vogt does provide some communal solutions in the final chapter of his book. He recognizes that:

So far [his] advice [is] directed toward individuals … But a change in consciousness within any number of individuals will not be enough to transform the contemporary experience of dying from an unspeakable horror into an endurable tragedy. The efforts of individuals must be supported by communal practices in order to bring about noticeable change.²¹

Regarding Christian communal practices, Vogt wonders whether parishes could create volunteer organizations that would provide company to those at the end of life. These individuals would assure that a person remains connected to the community of the parish even as their souls begin to separate from this world. In my opinion, such a practice could help to witness before the world the virtue of mercy, such as defined by James Keenan: to enter into the chaos of another.²²

Families, however, are not the only ones required to help alleviate the burden of death. Our broader relationships as friends, co- workers, Christian brothers and sisters, and neighbors ought to fuel a sense of duty and courage to enter into that chaos and give our support to those in their last stages. Kaveny, Vogt and other virtue ethicists urge for personal practices that would help develop the inner dispositions to face death. This same power of practices could then be extended to help develop social virtues of mercy, solidarity, and charity in the wider community.

PRACTICES: FAITH AND SOCIETY
So what would this look like practically? Lisa Cahill knows the challenge this question entails when she states, "Modifying social practices toward wise and just solidarity with the dying demands the imaginative and practical introduction of a new horizon of meaning regarding these life experiences and events."²³ We as Christians, and fellow humans have the charge to find new and creative paths towards changing society's approach towards death.

One obstacle to this change in modern times is the rise of death in hospitals. Death has become separated from our daily lives and therefore remains a mystery. It is constantly portrayed as an individual agony and personal suffering which needs to be sequestered or otherwise might infect the wider community. In response, Cahill praises the rise of hospice care as recognizing the needs of the dying and the duty of the living.²⁴ Perhaps re-incorporating death into the mainstream, while giving recognition towards the hospice movement, would allow people to become more familiar and hopefully more comfortable approaching a dying individual. Vogt's suggestion of creating a hospice care team seems like a brilliant idea for re-integrating death, a dying person, and the parish community.

The Christian sacraments can also help to re- incorporate the dying with the parish. Groups of individuals can go with the priest to give the anointing of the sick. Parish leaders can be there for the grieving family. We have already begun to once again include the sacrament of baptism into the Sunday liturgy. Perhaps more could be done with the passing of a parish member beyond simply giving times for the funeral and wake. Such a practice may include a short eulogy, pictures of the deceased near the altar, or a prayer of thanksgiving for their entering into the kingdom of heaven. These would help recognize the value of the person to the broader parish community, as well as provide resources for those who are nearing the end of their lives.

Finally, we need to change the view of autonomy, especially the negative judgment on burden and asking for help. I am thinking about the parable of the Good Samaritan. This story in Luke's Gospel often acts as an example for the Catholic health care ministry. However, we always focus on the Good Samaritan and the manner in which he helped the stranger. What I find more fantastic in this story is the way in which the robbed man had the humility to allow a stranger to help. Could we, in our society, praise such behavior? Could we imitate the beaten man in asking a stranger for aid? Unfortunately, I think the answer is currently no. This needs to be changed if we want people to use the resources that we hope will one day be available to all.

CONCLUSION
The current legal and political debate on physician-assisted suicide does not mirror the real-world experiences of the dying. Society's views on autonomy, the church's teaching on suffering and burden, and the heroic nature of independence are currently fueling the support for these bills. The ars moriendi tradition being upheld today requires a broader sense of community. The problems inherent in our society cannot be properly addressed by only changing the inner disposition of the dying towards a greater cultivation of virtue. Instead, we must look towards broader social and systematic changes. It is when society can courageously enter into the chaos, extend its hand of support, and encourage the dying to take hold that will we truly overcome the darkness of death.

NATHANIEL BLANTON HIBNER, PH.D.
Director of Ethics
The Catholic Health Association of the United States
St. Louis
[email protected]

ENDNOTES

1. Compassion and Choices, https://www.compassionandchoices.org/who-we-are/about/
2. Cathleen Kaveny, Law's Virtues: Fostering Autonomy and Solidarity in American Society (Washington: Georgetown University Press, 2012), 166.
3. David McCarthy, Sex and Love in the Home (London: SCM Press, 2001), 68.
4. Ibid., 77.
5. Lisa Cahill, Theological Bioethics (Washington: Georgetown University Press, 2005), 118. My emphasis.
6. JoAnne Marie Terrell, "Our Mothers' Gardens," in Cross Examinations (Minneapolis: Augsburg Fortress, 2006), 49. My emphasis.
7. Christopher Vogt, Patience, Compassion, Hope, and the Christian Art of Dying Well (New York: Bowman & Littlefield), 131.
8. Ibid., 4.
9. Ibid., 4.
10. Kaveny, Law's Virtues, 143.
11. Ibid., 144.
12. Ibid., 145.
13. Ibid., 146.
14. Vogt, Patience, 131.
15. Ibid.,152.
16. Ibid., 153.
17. Ibid., 155.
18. Ibid., 145.
19. Ibid., 173.
20. Ibid., 175.
21. Ibid., 136. My emphasis.
22. James Keenan, The Works of Mercy, (Sheed and Ward: Lanham, MD, 2005).
23. Cahill, Theological Bioethics, 120.
24. Ibid., 121.