Ethics of Care at the End of Life in Samaritanus bonus

Rev. Dr. William Eronimoose MI, Ph.D


The Letter Samaritanus bonus on the care of persons in the critical and terminal phases of life from the Congregation for the Doctrine of the Faith (CDF) was published on 14th July 2020, liturgical memorial of St. Camillus de Lellis, the Founder of the Order of the Ministers of the Infirm (Camillians), the Patron Saint of the sick, nurses, hospitals and of all healthcare personnel. This Letter clearly expounds the Church’s ethical position at the end of life after so many years of Jura et Bona published in 1980 by CDF.

The Letter implicitly brings to light and life the 16th century Saint Camillus de Lellis who with his new school of Charity was a revolutionary in caring for the dying persons who were treated without dignity and who were succumbed into a throw-away culture of those times. At this time of a lack of an ethics of care with a particular reference to pastoral care to the dying, the Letter implicitly extols the ethics of care of St. Camillus de Lellis. In the footsteps of this Saint, this Letter invites the healthcare personnel, the family people of those at the critical stage, the pastoral care ministers, the volunteers, the Christians and the people of ‘good will’ to promote the ethics of care so that the sick at their terminal stage should be respected and cared for with the style of Jesus Good Samaritan who goes out of his way to aid an injured man and encounters him and cares for his wounds and suffering with “the oil of consolation and the wine of hope.

Intervention of the Church through Samaritanus Bonus

The intervention of the Church is to make the style of the Good Samaritan concrete, translated into a readiness to accompany a suffering person, and to offer this assistance to respect and promote the intrinsic dignity of ill persons, their vocation to holiness and the highest worth of their existence. When advances in medical technology without any moral discernment claims to define the meaning and value of human life, the Letter hopes in scientific research and technology a service for the integral good of life and dignity of every human being, a rediscovery of the bond of trust between physician and patient, a respect for the ethical and legal boundaries that protect the sick person, a reaffirmation of the value of human life, the meaning of suffering, and the significance of the interval preceding death, and a reconsideration of the inherent human dignity that is proper to every person. The precise intervention of the Letter is: 1) to reaffirm the message of the Gospel and its expression in the basic doctrinal statements of the Magisterium, and thus to recall the mission of all who come into contact with the sick at critical and terminal stages; and 2) to provide precise and concrete pastoral guidelines to deal with these complex situations at the local level and to handle them in a way that fosters the patient’s personal encounter with the merciful love of God.

Nutshell of Samaritanus bonus

The nutshell of Samaritanus bonus is an “Ethics of Care at the End of Life.” It is because the importance of this Letter lies in an ethical position that is combined with pastoral care in the footsteps of Jesus to give meaning and hope to fragile human life at the end of life with the support of the healthcare personnel and the family. The well-trained and well-qualified pastors are to help them through their spiritual and pastoral accompaniment to discern so well as to avoid any unethical human act such as euthanasia and assisted suicide. In this way, this Letter is a very good module and manual for the pastors to help the healthcare personnel and the faithful to understand their questions and uncertainties about medical care, and their spiritual and pastoral obligations to the sick in the critical and terminal stages of life and to help to become a “healing community” to actualize concretely the desire of Jesus that all may be one flesh.

Paradigms and Principles at Play in Samaritanus bonus

The Letter calls to respect two paradigms: 1) the value of human being is the moral norm of reference, (the dying person is norm of morality) and 2) openness to the metaphysics as the horizon of meaning (the physical life opens up to the transcendental life in God). In the light of these two paradigms, this ethics of care expands on 4 principles to be respected, namely, 1) the criterion of judgment is at the end of life is the concrete dying person for his good and when he is not in a position to decide the family decide but always for his good, 2) do whatever is possible for the benefit of the sick person assisted by the family and by others in solidarity and subsidiarity, 3) do the only possible, needed for the person, and 4) do the best possible, that is, through a continuity of care.

Respecting these two paradigms and 4 principles at the end of life is paramount so as to avoid or conscientiously object i) any anticipation of death through Euthanasia and Assisted Suicide, ii) any postponing the death through Therapeutic Tenacity (aggressive treatments), and iii) any Therapeutic Abandonment, that is, any refusal to carry out proportionate treatments which bring benefit to the person like hydration and nutrition as necessary for the dying person to avoid starvation with an openness to stop this when it is futile.

This ethics of care is open to the transcendental value of human life revealed in Jesus, God in human form, the Good Samaritan, whose very life and death on the Cross paved way for a participatory redemptive meaning to the suffering and whose Resurrection paved way for a grace of hope to the human life which has its final destiny only in God when it is time to reach Him through a dignified care due to the dying human person.

Foundations for an Ethics at the End of Life

The foundations for an ethics at the end of life according to the Letter are explained very well in the first 3 chapters of the Letter.

The 1st foundation is care for one’s neighbor: Human vulnerability is a mystery which is encoded in our nature and which forms the basis for an ethics of care. It is expressed in concern, dedication, shared participation and responsibility towards all entrusted to us for material and spiritual assistance in their hour of need. It is expressed in the principle of justice, transformed by Jesus into the golden rule “Do unto others whatever you would have them do to you” (Mt 7:12) and echoed in primum non nocere of traditional medical ethics.

Care for life is therefore the first responsibility that guides the physician through a “therapeutic art,” which entails robust relationships with the patient, with healthcare workers, with relatives, and with members of communities. This responsibility exists not only when the restoration to health is a realistic outcome, but even when a cure is unlikely or impossible, not only when it attends to body’s functions but also to psychological and spiritual well-being of the patient.

Ethics of care departs from Jesus Christus Medicus who as the Good Samaritan not only draws nearer to the man he finds half dead but also he takes responsibility for the vulnerable by investing in him not only with the funds he has on hand but also with funds he does not have. This Christus Medicus identifies himself in every person sick as ‘Christus patiens” (cf. Mt 25:40) with a universal solidarity. This solidarity invites the healthcare personnel to become like Jesus the Christus Medicus to take care of the patient Christus patiens, to ‘every patient’ with the universal scope to ‘show care’ for the life of everyone and thus to reveal the original and unconditional love of God, the source of the meaning of all life.

Ethics of care in medicine must accept the mystery of death as part of the human condition and this mystery must be communicated to the sick both with great humanity (physical life is not something to preserve at all costs) and with openness to a supernatural horizon (bodily life is open to God). Responsible communication with the terminally ill person about his death should make it clear that care will be provided until the very end: “to cure if possible, always to care. The pastoral care of all – family, doctors, nurses, and chaplains – can help the patient to persevere in sanctifying grace and to die in charity and the Love of God without hastening death through euthanasia or assisted suicide.

The 2nd foundation is the living experience of the Suffering Christ and the proclamation of hope: Christ’s suffering has become the grace of hope for those who suffer because of his nearness to them: his experience of multiple forms of pain and anguish resonates with the sick and their families during the long days of infirmity that precede the end of life.

Christ’s experience resonates with the sick persons who are often seen as burden to society; their questions are not understood; they often undergo forms of affective desertion and the loss of connection with others; they are not heard; they are neglected; they feel lonely and tormented by the prospect of physical pain. In this situation, to turn one’s gaze to Christ is to turn to him who experienced all the suffering of the world: physical suffering, psychological suffering, moral suffering, and spiritual suffering. In the face of all these sufferings, Jesus became sign of hope – a sincere hope, capable of facing the moment of trial and the challenge of death.

The Mother and his disciples also give hope to Jesus on the Cross through their ‘remaining’ under the Cross. Though “remaining” they appear impotent and resigned, yet they provide the affective intimacy that allows the God made man to live through hours that seem meaningless. This reveals the fact that the end of life is a time of relationships, a time when loneliness and abandonment must be defeated. With Christ at the centre, the light of faith enables us to witness to a Trinitarian presence where Christ trusts in the Father thanks to the Holy Spirit who sustains his Mother and his disciples. In this way “they remain” at the foot of the Cross, they participate, with their human dedication to the Suffering One, in the mystery of Redemption. To contemplate the living experience of Christ’s suffering is to proclaim to men and women of today a hope that imparts meaning to the time of sickness and death. From this hope springs the love that overcomes the temptation to despair. Christian response to the problem of suffering at the end of life is not seen as a solution to the problem but as a certainty of a presence, a remaining, a nearness, a proximity, which was given to Job by God in OT, relived by Christ during His earthly existence, and continued in the care of the Saints and believers and re-continued by us today for those at the end of life.

The 3rd foundation is human life as a sacred and inviolable gift: it is because human life is not available to anyone, or to oneself. Sanctity or dignity of life presupposes unavailability of life which is inviolable. Whatever their physical or psychological condition is human persons always retain their original dignity as created and are called to exist in the image and glory of God. Their dignity lies in this vocation. The ultimate foundation of human dignity is that God became man to save us, promises us salvation and calls us to communion with Him. This is a participatory dignity and therefore even the weakest do not lose their dignity and it is proper for the Church to accompany them with mercy in their journey of suffering, to preserve them the theologal life, and to guide them to salvation.

Everyone is called to have the “heart that sees” which is central to the program of the Good Samaritan. A heart that sees converts the gaze of the heart, sees where love is needed and acts accordingly and identifies in weakness God’s call to appreciate that human life is the primary common good of society. The heart sees life as a sacred and inviolable gift and every human person, created by God, has a transcendent vocation to a unique relationship with the One who gives life. This heart sees human life as a highest good and it is always a good and society is called to acknowledge this and to grasp the profound reason why this is so.

This inalienable dignity is something already knowable by right reason, and in the light of faith it is confirmed and understood. The uninfringeable value of life is a fundamental principle of the natural moral law and an essential foundation of the legal order. Therefore, to end the life of a sick person arbitrarily is to disavow the value of freedom, life, human relationship, meaning of his existence and his growth in the Godly life. Moreover, it is to take the place of God in deciding the moment of death.

Cultural Obstacles that Obscure these Foundations

Care for one’s neighbor has its departure in Jesus’ living experiences on the Cross which proclaims hope to those who are at the end of life so that their life can be protected from aberrant unethical practices of today because God the Creator offers life and dignity to humans as a precious gift to safeguard and nurture, and demands that humans should be accountable to Him through a life of nearness and proximity either for themselves or for others. But there are many obstacles that obscure or diminish our sense of the profound intrinsic value of every human life.

The first obstacle lies in the notion of “dignified death” as measured by the standard of the “quality of life.” This utilitarian anthropological perspective views life as worthwhile only if it has an acceptable degree of quality as measured by the possession or lack of particular psychological or physical functions, or sometimes simply by the presence of psychological discomfort. A second obstacle is a false understanding of “compassion.” In the face of seemingly “unbearable” suffering, the termination of a patient’s life is justified in the name of “compassion”. This so-called “compassionate” euthanasia holds that it is better to die than to suffer, and that it would be compassionate to help a patient to die by means of euthanasia or assisted suicide. A third factor is a growing individualism which is thematized as “right to solitude” and the “principle of permission-consent” that can be extended to the choice of whether or not to continue living. This “right” underlies euthanasia and assisted suicide because of the dependence and inability to realize a perfect autonomy and reciprocity.

All these three factors in the words of Pope Francis are leading a “throw-away culture” where the victims are the weakest human beings, who are likely to be “discarded” when the system aims for efficiency at all costs. This cultural phenomenon, which is deeply contrary to solidarity, St. John Paul II described as a “culture of death” that gives rise to real “structures of sin” that can lead to the performance of actions wrong in themselves.

The Teaching of the Magisterium

In the light of these foundations and in the context of negation of these foundations by factors of false notion of dignified death, false understanding of compassion and growing individualism which lead to a culture of death and throw-away culture, the teaching of the Magisterium boldly expounds its undeniable ethical position for an ethics at the end of life. The teaching of the Church through this Letter SB invites Christians and all the people of ‘good will’ towards an ethics of care when cure is not possible.

The following 12 points are the summary teaching of the Church

  • The main ethical position of the Church is a clear-cut ‘No’ to Euthanasia and Assisted Suicide. It is because they are intrinsically evil acts in every situation in action or omission or in intention; it is a crime against human life and a grave violation of the Law of God. So there should not be any formal or immediate material, active or passive cooperation or any form of complicity.
  • As euthanasia and assisted suicide are intrinsically evil human acts, there is the moral obligation to exclude aggressive medical treatment so as to precipitate death or delay it. The renunciation of extraordinary and/or disproportionate means is not the equivalent of suicide or euthanasia; it rather expresses acceptance of the human condition in the face of death or waiving disproportionate treatments which have little hope of positive results.
  • No to euthanasia, assisted suicide and to disproportionate treatment entails basic care with the requirement of ordinary treatment with administration of the nourishment and fluids needed to maintain bodily homeostasis. When the provision of nutrition and hydration no longer benefits the patient, their administration should be suspended.
  • For dying persons, continuity of care through palliative care (PC) is part of the enduring responsibility. PC is an authentic expression of human and Christian activity of providing care, tangible symbol of the compassionate “remaining” at the side of the suffering person. Palliative Care Acts and End-of-Life Laws along with Medical Assistance to the Dying with openness to euthanasia and assisted suicide should not be supported. Palliative interventions with administration of medications to hasten death and suspension or interruption of hydration and nutrition when death is not imminent are equivalent to a direct action or omission to bring about death and are therefore unlawful.
  • While palliative care is the continuation of the care to avoid unethical acts, the role of the family with the support of the others is central to the care of the terminally ill patient. It is essential that the sick under care do not feel themselves to be a burden, but can sense the intimacy and support of their loved ones. Hospice centers are an example of genuine humanity in society, sanctuaries where suffering is full of meaning. For this reason, they must be staffed by qualified personnel, possess the proper resources, and always be open to families.
  •  In the context of growing number of pre-post natal euthanasia, accompaniment and care in prenatal and pediatric medicine is a must. Beginning at conception, children suffering from malformation or other pathologies are little patients and they should not be left without assistance, but accompanied like any other patient until they reach natural death. Prenatal comfort care favors a path of integrated assistance and Prenatal Hospice Centers provide competent medical assistance and spiritual accompaniment which are an essential support to families who welcome the birth of a child in a fragile condition with.
  • To mitigate a patient’s pain, analgesic therapy employs pharmaceutical drugs that can induce loss of consciousness. Accepting pain through the lens of Jesus’ redemption is a special offering to God. Still the Church affirms the moral liceity of sedation as part of patient care in order to ensure that the end of life arrives with the greatest possible peace and in the best internal conditions. But any administration that directly and intentionally causes death is a euthanistic practice and is unacceptable. Caregivers are obliged to alleviate the child’s suffering as much as possible, so that he or she can reach a natural death peacefully. From a pastoral point of view, prior spiritual preparation of the patients should be provided so that they may consciously approach death as encounter with God.
  • An important and crucial position of the Church is that subjects who are in the vegetative state and the state of minimal consciousness with autonomous breathing capacity are human persons with all of the dignity. In these states of greatest weakness, the person must be acknowledged in their intrinsic value and assisted with suitable care with the right to nutrition and hydration with the principle of ordinary means.
  • There is no right to assisted suicide or to euthanasia. The one authentic right is the sick be accompanied and cared for with genuine humanity. It is never morally lawful to collaborate with laws which induce immoral actions or imply collusion in word, action or omission. Christians, like all people of good will, are called to conscientiously object laws that are against the Law of God. Governments must acknowledge the right to conscientious objection. The right to conscientious objection does not mean that Christians reject these laws in virtue of private religious conviction, but by reason of an inalienable right essential to the common good.
  • Pastoral accompaniment (PA) and the support of the sacraments prepare the dying to encounter God. PA together with “healing resources” of prayer and sacraments with the qualities of Good Samaritan and with human and Christian virtues is a doorway to God. The ministry of listening and consolation that the priest is called to offer symbolizes the compassionate solicitude of Christ and the Church and it can and must have a decisive role. Given the centrality of the priest in accompaniment of the sick and the family, it is necessary that his priestly formation provide an updated and precise preparation in this area. It is also important that priests be formed in this Christian accompaniment. The sacramental moment is the culmination of the entire pastoral commitment to care that precedes and is the source of all that follows. The Church calls Penance and the Anointing of the Sick sacraments “of healing” for they culminate in the Eucharist which is the “viaticum” for eternal life.
  • PA is also extended to those who expressly ask for euthanasia or assisted suicide. With respect to the Sacrament of Penance and Reconciliation, the confessor must be assured of the presence of the true contrition necessary for the validity of absolution. When absolution delayed, it is a medicinal act of the Church, intended not to condemn, but to lead the sinner to conversion. Those who spiritually assist these persons should avoid any gesture, such as remaining until the euthanasia is performed, that could be interpreted as approval of this action. Such a presence could imply complicity in this act. This principle applies particularly to chaplains in the healthcare systems where euthanasia is practiced, for they must not give scandal by behaving in a manner that makes them complicit.
  •  A decisive step in the Letter is the importance of right education. Education has a critical role to play. Families, schools, other educational institutions and parochial communities must work with determination to awaken and refine that sensitivity toward our neighbor and their suffering. Hospital chaplains should intensify the spiritual and moral formation of the healthcare workers, physicians, nursing staff, hospital volunteers. The psychological and spiritual care of patients and their families must be a priority for pastoral and healthcare workers. Palliative treatments must be disseminated by organizing academic courses. Human and spiritual assistance must again factor into academic formation. Healthcare and assistance organizations must arrange for models of psychological and spiritual aid to healthcare workers who care for the terminally ill.

Concluding Reflections

The following are some of my personal reflections on Samaritanus bonus in the light of whatever is written above.

Earthly human life is full of small hopes to reach the highest hope of eternal life in God. Everyone’s experience demonstrates that these small hopes are always possible, even within a throwaway culture or a culture of death. These small hopes are nothing but “respect, defend, love and serve life, every human life.” The Church learns from the Good Samaritan these small hopes of care for the other. It is because he puts the face of his brother in vulnerability at the center of his heart, sees his need, and offers him whatever is required to repair his wound of desolation and to open his heart to the luminous beams of hope. The Samaritan’s “willing the good” draws him near to the injured man not just with words or conversation, but with concrete actions and in truth. It takes the form of care in Christ because He offers hope in times of all the sufferings of humanity which are recapitulated in Him and He invites us to offer the same hope.

Euthanasia and assisted suicide are actions against hope that are never a real service to the patient; they are always the wrong choice. In fact, since there is no right to dispose of one’s life arbitrarily, no healthcare worker can be compelled to execute a non-existent righ For this reason, it is gravely unjust to enact laws that legalize euthanasia or justify and support suicide. The legalization of assisted suicide and euthanasia is a sign of the degradation of legal systems, a sign of hopelessness. The Church calls for conscientious objection to these laws and invites us to discern in these difficulties an occasion for a spiritual purification that allows hope to become truly theological when it is focused on God and only on God.

Rather than indulging in a spurious condescension, the Christian must offer to the sick the help they need to shake off their despair. Knowing that earthly life is not the supreme value and ultimate happiness is in heaven, the Christian will not expect physical life to continue when death is evidently near but must help the dying to break free from despair and to place their hope in God. Therefore, the “end of life”, inevitably presaged by pain and suffering, can be faced with dignity only by the re-signification of the event of death itself by opening it to the horizon of eternal life and affirming the transcendent destiny of each person. Those who assist persons in the terminal stages of life must be able to “know how to stay”, to keep vigil with those who suffer the anguish of death, to console them, to be with them in their loneliness, to be an abiding with and to be a grace of hope.

Healthcare personnel with their therapeutic covenantwith the patient must recognize the transcendent value of life and the mystical meaning of suffering. In the light of this covenant, good medical care can be valued, while the utilitarian and individualistic vision that prevails today can be dispelled.

Catholic healthcare institutions are called to witness faithfully to the inalienable commitment to ethics and to the fundamental human and Christian values that constitute their identity. This witness requires that they abstain from plainly immoral conduct and that they affirm their formal adherence to the teachings of the ecclesial Magisterium. Any action that does not correspond to the purpose and values which inspire Catholic healthcare institutions is not morally acceptable and endangers the identification of the institution itself as “Catholic.”

The Letter invites all the people of ‘good will’ to care for the dying persons as we are also in need of the same care when human suffering touches us. It is the vulnerability of ours that invites us to care for others in their vulnerability.