The Nathaniel Centre

Child Poverty and Euthanasia: joining the dots

Sue Buckley and John Kleinsman

Child poverty and euthanasia are potentially risky topics for politicians in any year, but especially in an election year. The decision late last year to remove the End of Life Choice Bill from the private members ballot lest it become a political football is a demonstration of this caution. Is there a connection between these two contentious topics? The naming of the End of Life Choice Bill points to a possible link between the two, that of 'choice'.

Over recent decades the notion of 'choice' has been widely adopted in economic and social policy discussions, with human actors now widely viewed as autonomous individuals who have a fundamental right to make decisions on the basis of their own interests, whether in health, education, career, or lifestyle. Lifestyle decisions, such as what they spend their money on or how they spend their time or the sort of job they do, are seen as choices freely taken from a smorgasbord of options.

We have also come to view people's particular social and personal situations, including their unemployment and health status, more and more as the product of their prior choices. Without question, many people who are the recipients of a State sponsored benefit receive it because of circumstances beyond their control. Even when it seems that a person's situation may be the result of so-called 'bad choices', it remains the case that their personal choices cannot always be separated from the limitations imposed on their personal freedom by structural constraints beyond their control that define their particular societal and familial context.

As United States academics Kelly Brownell et al note, reflecting on whether we should pursue punishment strategies as a way of dealing with people who are obese: "environmental conditions can override individual physical and psychological regulatory systems that might otherwise stand in the way of weight gain and obesity, hence undermining personal responsibility, narrowing choices, and eroding personal freedoms."¹

Despite this fact, the overly simplistic view that people are essentially 'responsible' for the situation they find themselves in continues to shape the development of social benefit policies in many countries, including New Zealand. Thus, for example, where once it was held that benefits for sole or unemployed parents should be set at a level that would enable recipients and their children to participate in society like everyone else, now parents are exhorted to 'work their way' out of poverty. Consequently, those who are not able to achieve this become prone to seeing themselves, and to being seen, either as 'outsiders' or, at best, as 'unworthy' members of society.

In line with this, the notion of citizenship has also shifted over time, with a greater emphasis now on 'active citizenship' rather than 'passive citizenship'. While passive citizenship focuses on the rights that are inherent in being a citizen and belonging to a particular society, active citizenship focuses on responsibilities and obligations as the 'price' for belonging. In an article discussing the relationship between child poverty, child rights and active citizenship, O'Brien and Salonen² use the following definition of 'active citizenship': "A new ideal of citizenship or a new set of rights and duties based on a conception of a claimant (eg an unemployed person) as an active citizen. The active citizen is granted more autonomy and choice but in return is assumed to be self-responsible, flexible and mobile". It is implied here that the passive citizen should not expect to have the same rights or receive the same rewards. The subtle but powerful message is that those who, for a variety of reasons, do not work are 'second-rate' citizens because they 'reap the bounty of others' hard work'.

There are, of course, positive aspects to both views of citizenship; the concept of the 'passive citizen' is in the first instance associated with rights to food, shelter, work, free speech and so on, that are part of the inherent dignity of being human. Meanwhile the concept of 'active citizenship' is associated, in the first instance, with the relational responsibilities all human beings have towards each other, including the duties associated with contributing to the functioning of society and to one's own and one's family's wellbeing. However, an overly narrow focus on 'active citizenship' carries the risk of overlooking or disregarding those citizens who are, for any number of reasons, unable to be 'active'.

O'Brien and Salonen argue that changes in welfare policies over the last two decades in New Zealand have increasingly been based on the notion of 'active citizenship'. The setting of benefit levels and provision of tax relief for families have been intentionally designed to ensure that there is a clear economic advantage in working rather than living on a benefit. While this helps support 'working families', as noted above, it is also intended to encourage citizens to 'choose' work over unemployment. However, one of the unintended consequences of this policy shift is that those who are most vulnerable, children, the sick, the elderly and those with disabilities, who are not able to make such choices, are not just overlooked but become casualties of policies designed to reward and sustain the 'active'.

As O'Brien and Salonen note, the children of beneficiaries do not have a choice about whether their parents are in work or not and, if benefit levels are insufficient, then the children have poverty thrust upon them along with its associated effects on their long-term health and education. All of which means that a policy choice that favours rewarding parents in paid work can only be justified by a calculation that the gains which follow from providing an incentive to work outweigh the needs of the children of beneficiaries. This is clearly a utilitarian argument. Specifically, it neglects the real and immediate needs of many children who are presently living in poverty. It also fails to address the 'unpaid work' of nurturing involved in parenting,

Defining people as 'active' or 'passive' citizens and rewarding the economically active places children, the elderly and the disabled in the precarious position of having to claim rights as 'passive citizens'. In addition an overly narrow focus on the 'active citizen' means that 'passive citizens' become increasingly exposed to social censure. There is ample evidence in the derogatory connotations associated with welfare dependency that 'non-active' citizens are not only held in disrepute by others, but that they soon come to regard their own plight negatively. Consequently, there is little difference between being a 'non-active citizen' and becoming a 'burden on society'.

The use of political rhetoric that divides citizens into the 'deserving and underserving' makes this clear: 'strivers and skivers' (United Kingdom), and 'lifters not leaners' (Australia). Language such as this doesn't just alienate the unemployed, sole parents and other beneficiaries; it alienates all of us because we begin to view these groups of individuals as 'other'.

The focus on 'choice' and citizenship provides a useful lens for making sense of the controversial debate about choices at the end of life. In a society that accepts and emphasises the right and duty of people to make their own individual choices and the importance of taking responsibility for their personal situation, it naturally follows that the fundamental right, and possibly the duty, of the active citizen to choose how they live, should extend to choices about death.

However, the elevation of the 'active citizen' that informs recent welfare policies also risks creating classes of vulnerable citizens who are viewed, and view themselves, as a burden on society. Those particularly susceptible to this are the sick, the elderly and those with disabilities. Being seen as a 'burden' on the rest of society exposes these citizens to the same sort of criticism as beneficiaries and the corresponding weight of guilt that they are 'swallowing up resources'.

A widespread emphasis on individual autonomy and a social policy environment that defends and promotes the right to choose, with little regard to the limits of people's choices, can too easily obscure the negative impact of law changes that are justified on the basis of so-called choice, both on individuals as well as society at large. One outcome of this is that those of us who, through fortune or 'God-given' ability find ourselves healthy and well-off, can easily 'blame' others for their situation, blind to the deeper structural dynamics that inevitably shape and limit the choices people make; we can back away from child poverty and even tolerate it because their parents made bad choices; we can support and even champion the choice for euthanasia or assisted suicide while overlooking the social environment where those 'choosing' to die have come to see themselves as passive citizens, that is, as unworthy consumers of valuable and increasingly scarce resources – as 'lives unworthy of life'.
Supporting policies that allow for 'choice' might appear benign, but in an environment where some classes of citizens are at risk of being viewed and viewing themselves as unworthy or undeserving, providing 'choice' can be a negative and threatening experience. Just as the child of a beneficiary does not choose poverty, so those who see themselves, or are seen by others, as 'swallowing up resources', may find they have no real 'end of life choice' should our society make euthanasia and assisted suicide legal and acceptable options.

Sue Buckley is a researcher for The Nathaniel Centre and John Kleinsman is director of The Nathaniel Centre

1. Brownell, K. D., Kersh, R., Ludwig, D. S., Post, R. C., Puhl, R. M., Schwartz, M. B., et al. Personal Responsibility And Obesity: A Constructive Approach To A Controversial Issue. Health Affairs, 29(3), 379-387
2. O'Brien, M., & Salonen, T. Child poverty and child rights meet active citizenship: A New Zealand and Sweden case study. Childhood, 18(2), 211-226.

Kate’s Story: “The person inside the person with dementia”

Kate Burnett

Wednesday 15 January was an ordinary, sunny day at Cornwall Park Hospital. The residents were waking up to eat their breakfast for the day. Bur for one of our residents, this day would be unlike any other for quite some time.

When Jenny Smith (not her real name) woke this particular morning, she would be free from her crippling and cruel dementia. The staff were aware of the change from the very first moment they entered the room. Her usual furrowed brow was no longer so; in fact her features were very different; soft and loving. Her usual colourful language was replaced with words of kindness and joy. The staff bought her out into the dining room and for the first time in over a year she sat upright at the table and used a knife and fork to enjoy her breakfast.

This lady and I have an incredibly deep bond. I had been working here just a few days when she learnt that if she shouted my name I'd be straight there to give her anything she wanted, and so she did repeatedly 'Kate, Kate' morning noon and night. As the time went on I'd spend my working days with Jenny right by my side. I'd live for those moments when she'd briefly surface and I would get a hug or a kiss but those moments were few and far between. Jenny has a unique way of speaking, she comes up with the most imaginative and funny insults and phrases, just one of the reasons that I had come to love her so dearly. That being said, her high level of dementia makes her very troubled and highly distressed.

So when I walked into work that morning several staff approached me to tell me of the wonderful news. As I walked into the lounge there sat my companion with the sunniest of dispositions chatting with the nurse. As she looked over at me we both started to cry. She looked just like the lady in the pictures I'd seen of her before entering the hospital, she looked 10 years younger. She threw her arms out to me and we embraced like old friends who had been apart for too long. She put her hands around my face and studied it a while before saying 'take me to the garden there is much to discuss'.

I took her out into the sunshine and we sat by the rabbit cage as we so often did. Two of the other staff accompanied us as none of us wanted to miss a moment spent with the real Jenny. She discussed personal matters of importance such as which charities she'd like to donate her jewellery to and the health of family members. She could remember things I'd told her in detail such as my boyfriend's name and his profession. I was so overwhelmed at her memory and conversational skills; sometimes you wonder if the person inside the person with dementia is taking in what you are saying. It would appear from Jenny's awakening that they absolutely are. She took my hand and said to me; 'sometimes I'm so very cruel to all of you but none of you ever turn your back on me, from now on when I say the 'f' word I want you to imagine that I'm telling you how much I appreciate all of you.' I was sobbing almost uncontrollably at this point, I wanted to tell her how much she meant to me but the words wouldn't come out through the tears. She took the tissue out of my hand and dried my eyes and said; 'I have a lot of love for you Kate, I want you to always remember that'. At this point the other staff had gone back inside and we were alone, she lowered her voice and said to me; 'please answer this honestly Kate, I know you won't lie to me,' I nodded. 'Will the dementia return?' Sadly I nodded my head again, 'then how long do we have together?' I told her that I did not know, it could be a few minutes, maybe a few hours but we would cherish every second we had together. At this point she cried and told me that she badly wanted to stay. I told her I'd spend all of my prayers and wishes trying to make it so.

That afternoon Jenny's son and I took her out of the hospital. We drove her to the beach and she told me stories of when she lived there. We took her to church and she was overjoyed that all the features were just as she remembered them. After that we had afternoon tea and some of her family and friends came to visit with their children which Jenny was so pleased about. However, we could see that she was getting tired and were aware that we could lose her at any moment.

We got back in the car and I sat in the middle with my arm around her and she lay back against me. She kissed my hand and held it tight as we passed the beach where she had grown up. She said she'd never seen anything so beautiful and softly fell asleep. I held her tight to make sure she felt loved and safe.

She woke around 15 minutes later and bit into my arm with ferocious anger. We were all too aware that the dementia had returned. Her screams were louder than ever as we took her back into the hospital.

To this day, she has never resurfaced. She won't hug me and is repulsed when I kiss her cheek. No matter what happens, I'll always remember that a miracle happened at Cornwall Park hospital on Wednesday 15th January and I know that deep down in that person with dementia is a vibrant, intelligent and loving woman trying her best to tell me that I'm appreciated. And my goodness do I love that woman.

Kate Burnett is the Activity Officer at Cornwall Park Hospital, Epsom, Auckland.
This article first appeared in Dementia Care Briefing for Bupa NZ employees, Issue 14, March 2014 and is reproduced with the kind permission of the author and the resident's family.

Bringing Dementia Patients to Life

An insightful article on dementia written by Richard Gunderman: "a dementia diagnosis is not the medical equivalent of falling off a cliff" because there are many things that can be done to bring life to persons with dementia.

Available online at: http://www.theatlantic.com/health/archive/2014/01/bringing-dementia-patients-to-life/282802/

Catholic Health Australia releases new Advance Care Plan

The previous issue of The Nathaniel Report, number 42, included The Nathaniel Centre’s submission to the National Ethics Advisory Committee on the ethical challenges in advance care planning. In that submission we emphasised the need for a ‘process’ that emphasised the ongoing nature of end-of-life planning rather than a narrower approach that focussed largely on the completion of a written ‘plan’. We also highlighted the importance of people reflecting on decisions about care and treatment at the end of life before they become chronically ill. 

Some may imagine that the important decisions about end of life treatment are largely ‘technical’ ones requiring the specialist knowledge and advice of the medical profession. However, while the input of health practitioners provides a necessary and invaluable contribution, there are also issues of a spiritual, relational, social, cultural, emotional and psychological nature that are part of end-of-life planning. In particular, it is advisable to include those people who will be most deeply affected and who are likely to know us best – our family, whanau and aiga as well as significant friends.

The process of advance care planning can also be a good time to think about our willingness to become an organ donor.

In response torequests about advance care planning, Catholic Health Australiahas recently released two guides; one for people considering their future health care needs, and another for health care professionals. The guides are described as being consistent with Catholic principles as well as with good secular ethics. The documents have been approved by the Committee for Doctrine and Morals of the Australian Catholic Bishops' Conference.

The guide for people considering their future health care provides advice on a range of end-of-life issues. Because illness, disease and other life events are unpredictable, the document stipulates that it is best to provide general guidance about future medical treatment rather than specific directives. It also promotes the idea that the ‘planning’ take the form of an on-going conversation with family, friends and health care professionals.

The material features a discussion about choosing a representative in the event a person becomes unable to make decisions for themselves, as well as ideas for how to go about advising that person. The document underscores the responsibility we all have to protect and sustain life and details when treatment might be refused. It provides a good concise summary of the ethics concerning treatment which is futile and ‘overly burdensome’, what the Catholic tradition often refers to as ‘extraordinary’ or ‘disproportionate’. Treatments are burdensome when they cause distress and suffering for a person, cause difficulties for the person or their family (or the community) or are costly to obtain or provide. Persons are encouraged to clarify the burdens they would find acceptable.

Critically, the document notes that in light of the continuing debates over euthanasia and the withdrawal of medical treatment, it is important for a person to state explicitly that they do want life-sustaining treatment that is reasonable to be provided unless it becomes futile or is overly burdensome. The provision of food and water is part of the normal obligation to care for a person, even when a tube is required, so long as the food nourishes and /or alleviates suffering. The risk of choking, the failure to digest food, or the discomfort of a tube are all reasons which may make the use of tube feeding overly burdensome.

Finally the document provides ‘a model statement for future health care’, which can be used as it is or to begin a discussion about end-of-life planning with a person’s designated representative/s.

The document has been designed in a way that makes it easy to follow and it is appropriate for persons receiving care in any facility. While written with a Catholic audience in mind, it is equally suitable for persons of all faiths or none.  

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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.

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.

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.

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.