Vatican: PAV’s latest publication condones euthanasia and assisted suicide

The Pontifical Academy for Life (PAV), presided over by Archbishop Vincenzo Paglia, has recently published a booklet entitled Piccolo lessico del fine vita (Compact Lexicon of the End of Life ), edited by Libreria Editrice Vaticana. It is a selected glossary of terms pertaining to the subject end-of-life. Some elements of light exist in the booklet, but the areas of darkness dominate. As it’s not possible to analyse all the critical junctures present in PAV's publication, this article will dwell only on one point, the most critical point, which is as follows: PAV is in favour of euthanasia masqueraded as a rejection of therapeutic obstinacy (or a rejection of unreasonable obstinacy in treatment) and is in favour of assisted suicide.

Let us begin with the first problem. First of all we note that in the booklet the denunciation of euthanasia is limited, despite the fact that it is now a social phenomenon, while the insistence on the theme of therapeutic obstinacy is absolutely preponderant. But let us go into the merits. It is considered licit to refuse life-saving treatment by appealing to an objective and a subjective principle. The objective criterion refers to the possibility that life-sustaining treatments may constitute futile treatment. PAV makes this possibility explicit when dealing with Advance Treatment Provisions (DAT). The booklet does indicate some (but not all) structural weaknesses of the DAT - out-of-date, incompetence of the declarant, generality, difficulty of objective interpretation - but in the end it approves of this instrument, so much so that at the end of the booklet it even proposes an example of a DAT form for Italians to refer to.

So, not only does it approve of the practice - which is generally used for euthanasia purposes and therefore should not in principle be sponsored - and its corollaries such as the figure of the trustee (equally problematic due to the risks of voluntary or involuntary manipulation of the content of the declarations), but it even considers its content as binding: 'Their value cannot be understood in a merely preferential sense' (p. 36). Moreover, it recalls Italian law 219/17 without levelling any criticism at it, even though it is clearly a pro-euthanasia law. As the PAV is an organ of the universal Church, it is not clear why almost exclusively Italian regulations are referred to throughout the booklet.

But let us come to the lawfulness of refusing life-saving treatment. In the DAT form proposed by PAV, the registrant may have the freedom to refuse 'blood transfusions, antibiotics, life-sustaining treatments such as invasive and non-invasive mechanical ventilation, trachestomy, haemodialysis and [even] cardio-pulmonary resuscitation' (p. 79). It also opens up the possibility of refusing assisted nutrition and hydration (pp. 54 and 79). PAV considers it permissible to discontinue these therapies because they could constitute futile treatment. It is true that in rare cases each of these treatments could be useless if not harmful, but these are just exceptional cases: the state of deep cachexia that prevents nutrition and hydration; in the face of a very compromised pulmonary structure it is counterproductive to insufflate air by mechanical ventilation; the massive crushing of the skull following a car accident makes cardiopulmonary resuscitation useless, etc...

But PAV is careful not to specify that these are rare cases and to adequately exemplify them, and instead makes it clear that life-support treatments can also be refused because they can commonly constitute therapeutic obstinacy. Hence their inclusion in the DAT. But life-sustaining treatments are almost always effective precisely because they keep the patient alive. The perspective from which the PAV moves is therefore not that centred on the dignity of the person, but on the quality of life, so much so that among the criteria indicated to understand whether a treatment is proportionate or not are also included the quality of relations with third parties and economic burdens, which in the abstract may also be valid indices, but only in such residual cases that, even in this case, it is unreasonable to make them explicit in the Dats.

PAV is aware that according to medical casuistry and, above all, scientific literature, life-saving treatments most often do not constitute futile treatment. Here then is recourse to the second criterion mentioned earlier, the subjective criterion, which is the decisive criterion for opening the door to euthanasia: if the patient believes that a certain treatment is disproportionate, then it certainly constitutes futile treatment, beyond the scientific evidence. It therefore insists on the fact that "the decision is the patient's" (p. 25); that treatments must be "calibrated [...] according to criteria of [...] effective correspondence with the patient's requests" (p. 48) and with "his spiritual values and needs" (p. 58). And more explicitly: 'Even if the treatments were clinically appropriate, they might nevertheless be disproportionate if the sick person considered them too burdensome in his circumstances. Not to undertake or to suspend those treatments is, at this point, not only possible, but, as Pope Francis says, 'dutiful'" (p. 64). So the subjective must prevail over the objective.

Then, with regard to assisted nutrition and hydration, reference is made to a particular passage of a Note of the Congregation for the Doctrine of the Faith of 2007, which considered these means of life support disproportionate when there is an 'excessive burden [and a] significant discomfort linked, for example, to complications in the use of instrumental aids'. Thus, rare cases. PAV is careful not to quote the rest of the document, which refers to various magisterial pronouncements insisting that nutrition and hydration are almost always proportionate means. None of this. For PAV, nutrition and hydration become therapeutic obstinacy simply when there is mere "physical discomfort on the part of the patient" (p. 56), precisely because they have the final say.

And so, after indicating the criterion that refers to the scientific literature and the experience of medical personnel, "a second order of factors is also indicated, which concerns the onerousness and sustainability for the patient of the indicated interventions. Now, only the sick person can estimate the physical and psychic strengths he believes he has, also on the basis of his own reference values. [...] He has the decisive say in what concerns his own health and the medical interventions on his body' (pp. 63-64). The text at this point refers to the Catechism, which states: 'Decisions must be made by the patient, if he has the competence and capacity to do so, or, otherwise, by those legally entitled to do so, always respecting the patient's reasonable wishes and legitimate interests' (No. 2278). The reference to the Catechism is an own-goal because only the patient's reasonable wishes and legitimate interests, i.e. in accordance with justice, can be complied with, not unreasonable wishes such as the wish to die by refusing certain treatments. Of course it is a duty to listen to the patient to see whether certain treatments are bearable and how effective they are, but the final word rests with the criterion of objective beneficence of the treatments, not with the subjective criterion of the patient's absolute opinion.

Finally, PAV is in favour of the legitimisation of assisted suicide. In fact, we read with regard to suicide assistance: 'It is by examining these relationships [between the ethical dimension and legislative solutions] that reasons may emerge for questioning whether, in certain circumstances, mediations at the legal level in a pluralist and democratic society may be admitted. [...] Helping to identify an acceptable point of mediation between different positions is a way of encouraging the consolidation of social cohesion and a broader assumption of responsibility towards those common points that have been reached together' (p. 70). The idea of legitimising assisted suicide had already been expressed by Paglia in April 2023. Now qualifying conduct as legally legitimate means on a moral level considering it as just. Therefore, PAV considers suicide morally lawful. But suicide is instead an intrinsically evil action and as such cannot receive any legal legitimisation.