Vincent Van Gogh, 'The Good Samaritan', 1890 (detail)

Accompanying life, always

A document of the Congregation for the Doctrine of the Faith addresses the care of people in the critical and terminal phases of their life. A journey through the Letter 'Samaritanus bonus’.
Alberto Frigerio

On September 22, 2020 the Congregation for the Doctrine of the Faith published the Letter Samaritanus bonus on the care of people in the critical and terminal phases of life. Its objective, as it says in the Introduction, is to respond to the need for moral clarification and practical guidance in the face of technological advancement, which increases the power of medical practice to condition life processes, and by the new social context, which is marked by increasingly permissive international legislation on euthanasia and assisted suicide.

Chapter 1 presents the anthropological foundations, asserting that the human person, corpore et anima unus, is a limited and finite creature open to the Unlimited and Infinite, as evidenced by the demand for meaning that illness and the approach of death dramatically ask for. This is why there is an urgent need to adopt a notion of integral care, intent on addressing the physical, psychological, social and also spiritual needs inherent in the search for a meaning that allows one to appreciate the value of life, even in the time of illness, in which the most difficult and disturbing questions surface: why pain and suffering? What awaits me after death?

Chapter 2 identifies in the Crucified One the place where God's closeness to human pain and suffering is manifested. In him the evils of the world come together: physical, through torture and death on a cross; psychological, through betrayal, denial and abandonment; moral, through innocent condemnation; and spiritual, through a perceived distance from God. The event of Easter also offers the paradigm of the attitude of care, embodied by those under the cross: Mary, the other women, and John. Life finds justification in the experience of feeling loved and recognised in one's own unique value, especially in the most dramatic and agonising moments of existence.

Chapter 3 highlights the incalculable value of human life, which is a fundamental good insofar as it is a condition for the enjoyment of every other good, including freedom, which is therefore called to be lived responsibly. For this reason, killing a patient who asks for euthanasia does not mean recognizing their autonomy, which is strongly conditioned by the suffering to which they are subjected, but disregards the value of their life, precluding any further human relationship, the meaning of living and theological growth.

Chapter 4 describes the factors that currently limit the ability to grasp the value of life. First of all, utilitarianism, which focuses on psycho-physical well-being and neglects other deeper dimensions of existence, of a relational, spiritual and religious order. Then there is emotionalism, according to which compassion consists in causing the death of the suffering person instead of welcoming them, supporting them, and offering them affection and means to alleviate their suffering. Finally, individualism, which is the root of the harmful loneliness rampant today, attested by the impoverishment of relationships and the lack of solidarity.

Chapter 5 constitutes the doctrinal core of the document, which deals with various topics, including the prohibition of euthanasia, assisted suicide and aggressive treatments, basic and palliative care, the role of the family, prenatal and paediatric care, the conscientious objection of health workers, and the pastoral accompaniment of those requesting euthanasia and assisted suicide. There are three issues that are most relevant in regards to the current public debate. Firstly, euthanasia, which indicates the voluntary suppression of the patient with the aim of eliminating suffering, and assisted suicide, which indicates the act by which the patient takes his or her own life with medical assistance in order to put an end to suffering. On a moral level, both practices are inherently evil actions, which no further circumstances and intentions can justify. Life afflicted by pain and suffering is not unworthy, rather pain and suffering are unworthy of life, which is why euthanasia and assisted suicide must be rejected and all humanly and technically possible aid for the patient must be promoted.

At the legal level, the right to life constitutes the foundation of the legal system, as it is the basis of all other rights, including the exercise of freedom. Therefore, there is no right to arbitrarily dispose of one's life, rather one has a duty to take responsibility for it. At a clinical level, the demand for euthanasia and assisted suicide is related to unmanaged pain and a lack of hope, both human and theological, often induced by a lack of or inadequate human, psychological and spiritual assistance. Indeed, the pleas of the seriously ill are almost always anguished pleas for help and affection. Secondly, aggressive treatments, which refer to medical interventions that are inadequate for the sick person's situation because they are disproportionate to the results that might be hoped for and/or burdensome to them and their family. The text specifies that treatment is always due, insofar as it is intended to support basic physiological functions, at least for as long as the organism is able to benefit from them, while treatment aimed at counteracting an ongoing pathological process must be carried out using ordinary and proportionate means, i.e. clinically appropriate and subjectively not burdensome. Thirdly, basic care, among which the text lists nutrition and hydration, while omitting reference to respiration. The difference between nutrition and/or hydration and means of ventilation is due to the fact that the former provide substances that the body assimilates autonomously, while the latter also has the purpose of re-establishing an absent physiological function.

To conclude, Samaritanus bonus offers two main benefits. On a doctrinal level, it helps to make an ethical discernment on the use of life-preserving means, to be understood as a gradual process, which is the result of an evaluation of objective and subjective data, in a climate of dialogue between patient (or representatives) and health care providers. If the clinical and/or subjective assessment leans towards not adopting or suspending the means because it is futile and/or burdensome, care will continue in the form of palliative care, where interventions aimed at controlling physical symptoms (pain, dyspnoea, nausea, incoercible vomiting), psychological symptoms (anxiety, depression, anguish), spiritual symptoms (despair) and social symptoms (deterioration of relationships) related to the illness come together. The anthropological vision underlying palliative care follows the 'biopsychosocial-spiritual' model in which, as Daniel Sulmasy has written, “there is room not for separate parts of human reality to be divided among specialists, but for distinct dimensions that are always present and interrelated in the wholeness of the person.”

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On a pastoral level, it helps to grasp the educational value of pain and suffering, which correct the crudeness that often characterizes life ("Man in prosperity does not understand", Ps 48:13) and prepares us to ask for salvation, that is, deliverance from evil and death. On the other hand, pain has a disarming and dissuasive power, which can lead to despair. This is why Christians, together with men and women of good will, are called to care for troubled and afflicted life, bearing witness to the closeness and compassion of Christ who breaks the deadly chains of pain and suffering. This is what we read in the Conclusion, which refers to the image of the Good Shepherd, a paradigm of the care of life that the Lord's disciples are called to embody and witness.