Physician Assisted Suicide («PAS») – A Theological Approach

Introduction

The developments of contemporary medicine have contributed both to the prolongation of the average life span and to giving the probability of a longer survival of seriously ill patients despite their terminal dis­eases. Unfortunately, the prolongation of merely surviving is usually syn­onymous with the loss of the quality of life. Thus, nowadays, we cannot talk only about the fear and the psychological negation of death (1) but mainly about the fear of the dying process and of the painful conse­quences caused by the technological prolongation of a biologically con­demned life (2).

The fear of the dying process is not incomprehensible if we take into account the fact that in developed countries, only 10% are sudden deaths (including accident victims, suicides and murders) when 70-80% are due to degenerative diseases, characterized be a long lasting deteriorative process (3). Additionally, during the next 50 years, the world’s population of those over 85 years of age is expected to be five (5) times more than today and most will need long term hospitalization or medical and nursing care at home. According to the statistics, the average hospital­ization cost for an over 85-year-old patient is five (5) times higher than both that of a young patient and also that of the elderly ones (70-85 y.o.) (4) (5).

The social and economic consequences of the bio-medical achieve­ments in the prolongation of life, particularly in severe illnesses are ob­vious. Inevitably, questions that in the past one wouldn’t dare to utter are openly raised today. One such example includes the efficacy of the expenditure of a great amount of money to perpetuate the life of those men and women for whom there is little or no hope of «benefit» from this «investment» of money, where with the least amount of money we can save the life of a third world child (6).

Thus, new bioethical dilemmas are raised and also older ethical ques­tions come back enriched with new perspectives. Questions on Euthana­sia, on the limitations of the Principle of Autonomy on respect and maintenance of human Dignity in the face of sickness and death and on Medical Paternalism are again at the top list of the bioethical inquiries. Apart from these «classical» dimensions of the bioethical thought, some more «delicate» values and questions are made manifest, such as the sig­nificance and place of compassion in Medicine (7).

During the last decade, one of the more challenging issues, both in medical and in ethical and philosophical thought is the so-called «Physi­cian Assisted Suicide» («PAS»). In fact, «PAS» is a form of voluntary, active euthanasia, while the main idea is that a suffering patient or one who is aware of the predicted suffering patient can decide to kill himself. If he or she is not mentally disturbed, then a doctor is obliged to help him/her in committing a successful and painless suicide (8).

From the early 90’s, when Dr Jack Kevorkian (since the known as «Dr Death») was sentenced because he practiced «PAS», until now, when P.A.S is acceptable as a legal choice by some countries (i.e. Netherlands, England, etc) the scientific and the public discussion is growing in geo­metric proportions. Despite the seriousness o! this issue, there is a lack of Christian Orthodox theological argument on this matter. The purpose of this paper is to reflect on the discussion of «PAS» from both the the­ological and the psychological point of view.

 

Bioethical principles and «PAS»

Both supporters and opponents of «PAS» defend their stance with strong and well-developed arguments. During the last 2000 years medical deontology has been essentially influenced by the Hippocratic moral principles. It is not surprising that the most classic argument against «PAS» is the «Nonmaleficence Principle» («μη βλάπτειν»). According to the Hippocratic Oath, medicine must «above all do no harm». Conse­quently, any supply of a patient by his doctor with fatal medication or encouragement to use it is not permitted (9).

Paradoxically, the supporters of «PAS» confront this principle by us­ing a bioethical principle also originating from the Hippocratic moral values. They claim that the prohibition of «PAS» is equal to the restric­tion for a beneficial treatment (10)  (11). Therefore, this restriction is against the «Principle of Beneficence». This principle comes also as a directive from the Hippocratic writings and refers to the first duty of the two fundamental duties of the physician: «As to diseases, make a habit of two things -to help or at least do no harm» (12). If «Nonmaleficence» refers to the duty of «doing no harm» to the patient, «Beneficence» refers to the primary duty of «helping» the patient to «act in ways that promote the welfare of other people» (13).

In addition, the supporters of «PAS» argue that its prohibition is also against the «Principle of Autonomy», according to which «rational indi­viduals should be permitted to be sell-determining» (14).

Nevertheless, criticism against «PAS» has not been grounded mainly on autonomy (15)  (16), as it could be expected. In recent decades opponents of «PAS» argue that it offends some more humanistic and fundamental moral principles, like the duty to protect human dignity and the sanctity of life (17) (18) (19). It is worth mentioning that according to the opponents it is exactly the need to protect human dignity (20) and the right to a shame­less death that demands the legislation of «PAS».

Finally, there are also the practical questions, raised by some scholars who believe that the legislation of a voluntary, active euthanasia like «PAS» will provide various «slippery slopes» (21) (22); entailing more prob­lems than those it is supposed to solve (23).

 

Christian Orthodox approach of «PAS»

The Christian Orthodox approach of this controversial issue cannot sub-estimate the importance of all the aforementioned arguments. How­ever, it must be clear that Christian Orthodox tradition cannot see all the modern bioethical dilemmas and ethical values as self-determined moral values or as «ends to themselves». For the Orthodox Church it is essential for the bioethical dilemmas to be approached with criteria de­fined by the ontological dimensions of Dogmatics and not only by au­tonomous moral values. In other words, every moral value must be in a live and absolute relation to the basic elements of faith.

According to Orthodox Theology, ethics are the outcome of the Dog­ma, as Dogma prescribes the «ethos» i.e. the morals of each member of the Church, being as an ecclesiastical entity and not as a social unit. The formation of this ethos is not an achievement of the individual but an ecclesiastical fact (24). That is because the Church is not a socio-moral institution but a certain way of existing «in the Body of Christ» (25)  (26). In other words there is always a Priority of Ontology versus Morals and because of that Orthodox theology does not act like a «policeman» of morality but, rather, tries to understand and interpret the ontological dimensions and perspectives of any ordinary life problem.

Practically, the emphasis on the priority of ontology versus morals means that the evaluation of human behaviour cannot be based on au­tonomous, utilitarian moral principles but it presupposes criteria that seek those elements, which lead to overcoming mortality. In the mind of the ecclesiastical Fathers «for all that we do, God asks tor its purpose; whether we do it for Him of for another reason» (27). The main goal is the conquest of sanctity not only as a moral attainment but also mainly as an ontological achievement.

In the light of the aforementioned, it is easier to understand why, for the Orthodox Church, every bioethical principle -even those that are thought to be generally accepted or self-proved- (for example the Hip­pocratic principles of medical ethics), needs to be evaluated in the con­text of Christian ontology before it is accepted as objective authority and value.

The least remarks lead to another crucial question. Is it possible, as Christian Orthodox, to speak about issues concerning life and death with­out referring to our faith in the Resurrection of Christ? It is true, of course, that even today, twenty centuries after the appearance of Chris­tian teaching, it seems that we have not overcome the initial difficulty of the human mind to meet and incorporate the divine revelation. We still face the same resistance as St Paul faced when he spoke under the bright sun of ancient Athens. When St Paul addressed the Athenians for the first time, they were flattered by his challenging sermon. But this lasted only until he mentioned the Resurrection of Christ. «When they heard of the resurrection of the dead, some mocked: and others said, «We will hear you again of this matter» (28).

Besides the difficulty to introduce faith in Christ’s Resurrection as an important issue in the discussion on P.A.S., we cannot forget that it serves as a cornerstone of the Orthodox Confession. Consequently noth­ing is more important than conquering death, while death is the ulti­mate enemy of man (29) and there is no room for compromise with it (30). We should always have in mind that «if Christ is not risen, then our preaching is empty, and our faith is also vain» (31).

The ontological approach also entails the understanding of the human being as a Person and not only as an individual social unit. From the theological point of view, being a Person means being created according to God’s own «image» and «likeness». That is why being a person also means being a free existence, whose freedom extends to the possibility of negation or transgression of natural necessity.

It is worth mentioning that if we accept freedom of the human being as a main element which determines its existence as a person, then the crite­ria of evaluating his/her acts must be analogous. It means, for instance, that one cannot exist as an autonomous and self-determined unit. One can be a being only in relation to someone else or something else and in any case be something more than just an individual. As St Paul emphasis­es: «We do not live to ourselves, and we do not die to ourselves. If we live, we live to the Lord, and if we die, we die to the Lord» (32).

Recapitulating all the aforementioned we can conclude that some of the basic principles from the Orthodox point of view, which should be taken into account in the dialogue about «PAS», could be the following:

1. The priority of Ontology versus Morals.
2. The evaluation of bioethical principles according to Christian An­thropology.
3. The faith concerning Christ’s Resurrection.
4. The human being is a Personal existence and not only an individ­ual entity.
5. The evaluation of the motivations of human behaviour must be in its relation to God.

If the «aftexousion» («αυτεξούσιον», the freedom and inner-determination of the human being) (33) is recognized as a main element that de­termines the existence of the human being as a person, then the criteria for the evaluation of the human behaviour must be in accordance to this axiom (34). Consequently, the evaluation of the motives of human behavior must be based on how a person can surpass the borders of mortality, i.e. how can we realize sanctity as an ontological and not just as a moral achievement (35). It is obvious that the autonomous utilitarian moral prin­ciples cannot fulfill such demands.

 

Theology and Bioethics: convergences and divergences

Approaching the bioethical dilemmas under the light of all the afore­mentioned, it becomes easier to understand why the Orthodox Church is differentiated from or precautious about some of the bioethical princi­ples, which are thought as self-evident. For instance, the rejection of eu­thanasia -and of P.A.S. at large- by the Orthodox Church is based main­ly on the differentiation of the human being as a person from any other living creature, because the person is characterized by this freedom rather than by a de facto respect to the sanctity of life itself.

Some Orthodox theologians often adopt the protection of life’s sanc­tity as a main argument of Christians ethics against euthanasia. This is also a main topic of the Papal Encyclical «Evangelium vitae» (36). But, then, we should also accept that any kind of taking of any living crea­ture’s life must be forbidden as well, including every animal, while any form of life comes from God and belongs to Him (37).

Nevertheless, we need to clarify what is defined as a «person’s free­dom», because it seems that there is some confusion between the free­dom of a human being as a person (38) and the freedom of the individual defined by «human rights». From the Orthodox point of view there is al­ways a priority of Personhood versus Individualism in manner of exis­tence. According to the anthropology of Individualism, humans are free to be autonomous and determine their own will and even their own death. According to the anthropology of Personhood, death is not an individualistic matter but touches every personal relationship with the others or with God from which relationships the person emerges (39).

The last remark seems to be compatible to the psychoanalytical inter­pretation of suicidal behaviour. According to the classical proposal of psy­choanalysis on suicide, the destructive feelings of a suicide, which were turned initially against a beloved person, are «interjected» after a frustra­tion and they are turned against the subject itself. Finally, under the dom­ination of guilt and destructive emotions the subject is driven to self-de­struction, i.e. to kill him/her self (40). Arthur Miller underlines this dimension in his playbook «After the Fall» by putting on the lips of the actors the phrase «a suicide kills two people. Maggie, that’s what it’s tor» (41).

The difficulty in specifying the limits of Autonomy is often enforced by the congruency of the Principle of Autonomy and the protection of the freedom of the individual. Some writers argue that the support of «PAS» on the base of the principle of autonomy cannot be sufficient enough because it is absolutely depended on the latent cultural percep­tions of «good» (42). What is the objective value of individual autonomy in decision making when every choice is pre-determined be socially im­posed ideas about what constitute «good»? (43).

Indeed, the personalistic understanding of life means that any general moral principles founded on the utilitarian distinction between «good» or «bad», «right» or «wrong», «permitted» or «prohibited», more or less «useful» etc., cannot be stronger than, or have priority over, the sancti­ty and uniqueness of the Person. The criterion of common utility cannot be a sufficient end in itself because the human being as a person has ab­solute priority over any impersonal common good. For the same reason, opposing euthanasia by using the criterion of common interest does not sound very convincing because it places the Person on a lower level than the social interest.

The way Autonomy is usually comprehended seems to enclose hu­man freedom in the narrow borders of protecting utilitarian individual human rights (44). However, to exist as a person means to surpass individ­ualism and be raised to the level of a free and social being. Consequent­ly, both the relation with God and with people should be an expression of a personal free will and not the outcome of choices imposed by ex­ternal or utilitarian factors.

The Person is a tree and social existence and its relationships must be contested by itself and not imposed from the outside. One cannot be hetero-determined in life or in death by persons where there is no rela­tionship by mutual, real and unselfish love.

 

The problem of unconscious motives in medical decision making

The last thoughts bring to light an important fold associated with the way we legislate or make medical decisions in order to intervene for the prolongation of life or for the opposite, like the practice of «PAS». Legalisation of «PAS» gives the physician the chance to participate in the decision making of an individual who wishes to end his/hers life and to «co-operate» in the materialisation of this decision in a frame of pro­fessional rather than loving, interpersonal relationships.

This becomes more obvious when the psychiatrist is mobilised to judge whether the patient’s mental state ensures a rational and objective decision to kill him/her self. How morally fair is the transfer of the re­sponsibility for such a serious decision from the context of interpersonal relationships of a patient with the family or with other beloved persons or even with his/hers personal physician, to a stranger specialist (45)?

The situation becomes even more complicated if we take into ac­count the negligence of the pivotal importance of the patient’s or the medical professional s unconscious motives which do not usually ensure any rational, genuine and voluntarily free choices.

It is well known that the physician’s unconscious avoidance or anxi­ety, caused by the contact of medical staff with the diseases and their consequences, leads to transforming the treatment of a suffering person into a depersonalised treatment of damaged human organs. This «profes­sional» attitude is accepted as normal while the model of medical educa­tion is based on teaching how to confront diseases but not patients (46). In addition, this attitude is unconsciously mobilised for the relief of narcis­sistic injury, caused by the difficulty of the physician to control his own anguish or fear in the face of death by using defense mechanisms like negation or reaction formation.

Furthermore, the common experience that the suffering of the hospi­talized patient meets deep feelings of loneliness and isolation (47) seems to be neglected too. Consequently he/she retrogrades emotionally as he/she is compelled to be cared for by others in ways similar to previous, child­ish stages of dependence and emotional needs. The emotionally retro­graded patient feels his needs for dependence as a psychological con­flict. The patients hang from the scientific knowledge of their therapists in order to survive and at the same time the more dependant and help­less they become, the more humiliated they feel. Those feelings of hu­miliation, of anxiety and depression are communicated from the patient to the physician. So, the physician unconsciously de-personalises, the doctor-patient relationship.

Inevitably, some very inconvenient questions are raised, concerning bow scientifically validated and morally fair is the decision making pro­cess regarding both the interventions for prologation of life or «PAS». Are some of the medical interventions during the dying process always rationally and scientifically justified? Do they really express an empathetic attitude towards the patient? Do they correspond to the patient’s real needs? Is there, perhaps, an unconscious motive on the part of the medical staff to seek relief from their own weaknesses, guilt and despair that neglects patient interest?

 

The main argument: Dying with Dignity

The last remarks make particular sense not only with regard to the Principle of Autonomy, the Sanctity of life and the Principles of Benefi­cence and Nonmaleficence but even more with regard to the emphasis given in our times to the protection of human Dignity, to the right of dying with dignity.

Undoubtedly, Orthodox Theology is deeply concerned with the prob­lem of the degrading proceedings which accompany the journey to death. The «Gospel of The Final Judgement» (48) reminds us that Jesus Christ preaches about our obligation to look after our suffering brothers. Ac­cording to His commands, whoever does not feel compassion for the suffering fellow, who does not visit the sick, who does not look after the sufferer, neglects Christ Himself («as often as you did it for one of my least brothers, you did it for me») (49).

This awareness should not obscure the fact that voluntary acceptance of suffering is an element of Christian ethos according to the prototype of Jesus’ sufferance on the Cross. But it does not mean that the Church imposes pain as an ideal, as a wished condition, or that the Church un­derestimates human weakness and despair which is characteristic of the dying process. On the contrary, the Church always prays that «the end of our life may be Christian, painless, unashamed and peaceful». At the same time, it prays for «a good defense before the awesome judgment seat of Christ» (50).

We should also remember that there is a special prayer asking God to allow death to come in such cases where there is the possibility of the temptation of «PAS» (51). The purpose of this prayer is to beseech God to permit timely and painless death in such cases where the temptation of suicide or euthanasia appears almost inevitable. It is easy to conclude that the Church is not against a timely death when God permits it to come but not when it is provided as a human substitution of God’s will.

Even in those cases where mercifulness is used as an argument for «PAS» we should ask if there is any defining line between a «merciful» murder and «PAS», especially if we take into account the morbid, un­conscious motives presented as «compassion».

 

Suicide as a pastoral problem

The Orthodox Church never accepted or justified suicide (52). In the moral conscience of the faithful suicide is a proof of «aversion» towards the Creator (53). Distinct from that, the Church has always been aware of the tact that the way of Christian life is often strongly influenced by the cultural environment, which dictates these social mores not always in keeping with the Evangelical law. Reacting to these influences, the Church denies the Funeral Service to those who take their own lives, not as a punishment, but as a pedagogical method against suicide (54). This «restriction» already exists from 346 A.D. and it is mentioned in the biography of Abba Pachomios’ (55).

It must be clear and well understood that the negation of an ecclesi­astical funeral to those who kill themselves is not a penalty but a pre­ventive method whose aim it is to reduce the risk of suicide. It is note­worthy that the mentally disturbed are excluded from this restriction.

This practice is exercised already by the canonical demand of Timothy of Alexandria, which permits the formal Funeral Service to the «ekfreneis» («εκφρενείς»), i.e. to those who «have lost their minds» (56)  (57). Even to­day, according to the Canon Law, if one kills him/her sell and it is not clear if this occurred while he/she was in a state of madness at that time, then they should be buried ecclesiastically (58).

The Church preserves as the final criterion for the moral evaluation of such serious and blameworthy actions, the understanding of the mo­tives. Salvation and not justification is the important issue. Consequent­ly, the fundamental criterion is the motivating intention. A suicidal act, which is deemed an altruistic act, might be theologically incorrect. How- ever, the Church because of the honourable intention of the person who sacrificed him/herself does not condemn this choice.

Unfortunately, the ecclesiastical arguments are very often encountered as conservative or anachronistic. Neverthless, it is the duty of the Church to maintain its prophetic obligation, which is to indicate the po­tential consequences of life choices. For instance, the Church cannot compromise with the proclamation of the avoidance of pain as a higher good, for the sake of which even life must be sacrificed.

The warning of the danger of culture as a cause of a slip into slippery paths is not a rhetorical defense of the right to have a religious opinion on bioethical issues but it constitutes an expression of agony based on the historical experience. A typical example of such a tragic deviation is the way some particular groups of people have been treated in the past due to criteria accepted at that time as scientifically approved.

Long before the Nazi’s regime was settled, German scientists became very enthused with the idea of improving the human race through selec­tive breeding. Simultaneously, eugenics seemed very promising and the Germans were almost inspired by the sterilisation laws already applied in many states in the USA, which resulted in thousands of mentally ill pa­tients being involuntarily sterilized (59).

When Hitler came to power, the sterilisation of the mentally ill and particularly of those with a supposed genetic defect had been legislated. After some hundreds of thousands of such operations had taken place, the next step was legislation of the «euthanasia» of defective children and of the mentally ill and intellectually retarded.

The saved data shows that about 70,000 people were killed in Psychi­atric Hospitals until the program was officially called off after clerical protest in August 1941. Unfortunately, even after the scandal and the formal restriction of euthanasia, patients in Psychiatric Hospitals contin­ued to be hastened to death through neglect and starvation. P. Chodoff mentions that, «a further step on the road to Auschwitz occurred with what has been called the «medicalization of anti-Semitism, including the precepts of another pseudoscience -criminal biology- as Jews became defined as genetically diseased, a cancer that had to be eliminated to re­store the health of the German people» (60).

 

Conclusions

In our attempts to approach from a Christian perspective such diffi­cult and challenging issues like «PAS», we should remember that the Or­thodox Theology does not confront ethical dilemmas by editing general declarations and moralistic simplifications. Hence, the Orthodox Church also tries not to provide circulars of general moral principles, at least if it is not an absolute necessity. The Orthodox Church prefers to entrust to the priests, as spiritual fathers, the defining of the fundamentals of the faith according to the particularities of person, each of whom is given utmost respect (61).

Neverthless, the Orthodox Church cannot accept any kind of murder, including murder of mercy or «PAS», in the name of the «right to die with dignity». There is always an evident duty to protect any vulnerable person from the imposition on him/her of any conscious or unconscious morbid death desires by the relatives, the medical staff or the public health managers (!).

In the place of any other epilogue, we choose to cite a fragment of the patristic teachings that perfectly summarises our speculations on «PAS». St Isidore the Pelusian asks directly: «What forgiveness can be given to the soul who moved the hand?» (62).

It might be very helpful to those entrusted with the responsibility of decision making on issues that have existential extensions to ask them­selves: The hand or the mind that will help the adoption of self or social destructive choices, should expect what kind of forgiveness by God or by History?

 

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(1)Elizabeth Kübler-Ross, On Death and Dying, Macmillan, New York, 1969.

(2)Mark A. Duntley, Covenantal Ethics and Care for the Dying, in: On Moral Medicine, (eds) S.E. Lammers, A. Verhey, 1998, William B. Eerdmans Publishing Company, USA, pp. 663-666.

(3)Margaret, Pabst Battin, The Least Worst Death, Oxford University Press, New York, 1994, p. 9.

(4)David C. Tomasma, The Ethics of Physician-Assisted Suicide, in: Physician-Assisted Death, (eds) J.M. Humber, R.F. Almeder, G.A. Kasting, Humana Press, Totowa, New Jersey, 1993, p. 116.

(5)Stephen Post, Severely demented elderly people: A case against seniside, J. Am. Geriatr. Soc., 38, no. 6 (June), 1998, pp. 715-718.

(6)Gloria Maxson, Whole life Is It, Anyway? Ours, That’s Whose, in: On Moral Medicine, (eds) S.E. Lammers, A. Verhey, 1998, William B. Eedermans Publishing Company, USA, pp. 663-666.

(7)Fox M., A spirituality named compassion and the Healing of Global Village. Hampton & Row. San Francisco, 1979.

(8)Diane E. Meier, Doctors’ Attitudes and Experiences with Physician-Assisted Death, in: Physician-Assisted Death, eds. Humber J.M., Almeder R.F., Kasting Gr. A., Humana Press, Totowa, New Jersey, 1994, pp. 5-24.

(9) Ronald Munson, Intervention and Reflection, Basic Issues in Medical Ethics, Wadsworth Publishing Company, USA, 1996, pp. 32-34.

(10) Richard L. Rislay, A Humaine and Dignified Death: A new Law Permitting Physician Aid-in-Dying, Glendale, California: Americans against Human Suffering, 1987.

(11) Sidney Wanzer, Maintaining Control in Terminal Illness:   Assisted Suicide and Euthanasia, Humane Medicine, 6, no. 3, 1990. pp. 186-188.

(12) Ronald Munson, Intervention and Reflection, Basic Issues      inMedical Ethics, Wadsworth Publishing Company, USA, 1996, pp. 32-34.

(13) ibid, p. 34.

(14) ibid, p. 40.

(15) Dan Brock, Voluntary Active Euthanasia, Hastings Center Report 22, no. 2, 1992, pp. 10-22.

(16)Baruch Brondy, Voluntary Euthanasia and the Law, in: Beneficence Euthanasia, (ed.) M. Kohl, Prometheus Books, Buffalo, New York, 1975.

(17) Joseph Boyle, Sanctity of Life and Suicide: Tensions and Developments With­in Common Morality, in: Suicide and Euthanasia, (ed.) Baruch Brody, Kluwer Aca­demic Publishers, Boston, 1989, pp. 221-250.

(18) Richard Gula, Euthanasia: Moral and Pastoral Perspective, Paulist Press New York, 1994, pp. 24-28.

(19) Richard Roach, Medicine and Killing: The Catholic View, The Journal of Medicine and Philosophy, 4. no. 4, 1979. pp. 383-397.

(20) Leon Kass, Death with Dignity and the Sanctity     of Life, Commentary, March, 1990, pp. 33-43.

(21)Kathleen Foles, Competent Care for the Dying Instead of Physician-Assisted Suicide, NEJM 336, no. 1, 1997, pp. 54-58.

(22) Richard Fenigsen, A Case against Dutch Euthanasia, Ethics and Medicine 6, no. 1, 1990, pp. 11-18.

(23) Margaret Pabst Battin, Suicide: The Basic Issues, in: The Least Worst Death, Oxford University Press, New York, 1994, pp. 193-194.

(24) John D. Zizioulas, Being as Communion, St Vladimir’s Press, USA, 1997, p.15.

(25)Rom. 12:5.

(26) 1 Co. 10:17.

(27) Maximos the Confessor, Patrologia Cursus Completus, Series Greca (PG), ed. J.P. Migne, 90, 996C (in Greek).

(28) Ac. 17:32.

(29)1 Co. 15:26.

(30) John Zizioulas, Euthanasia, Enimerosi ton giatron, vol. 158, Athens, Greece, 2001, pp. 14-22 (in Greek).

(31) 1 Co. 15:14.

(32) Rom. 14:7-8.

(33) Vladimir Lossky, The mystical theology of the Eastern Church, James Clarke and Co. Ltd, Cambridge and London, 1968, p. 115.

(34) John Zizioulas, Christology and existence, Synaxe, vol. 2. 1982, pp. 9-20, (in Greek).

(35) Constantine Skouteris, Bioethics and the Ethos of Orthodoxy, Annals 2-3 1999-2000, 2000-2001, St John Damascus Institute of Theology, University of Balamand, pp. 81-99.

(36) John Paul II, Encyclical Letter, given in Rome, at saint Peter’s, on March 1995.

(37) John Zizioulas, Euthanasia, Enimerosi ton giatron, vol. 158, Athens, Greece, 2001, pp. 14-22 (in Greek).

(38) John Breck, The Human Person: From Image to Likeness, in: The Sacred Gift of Life, St Vladimir’s Seminary Press, Crestwood, New York, USA, 1998, pp. 28-32.

(39) John Zizioulas, Euthanasia. Enimerosi ton giatron, vol. 158, Athens, Greece, 2001. pp. 14-22 (in Greek).

(40) Nadine J. Caslow, Susan L. Reviere, Susan E. Chance, James H. Rogers, Car­rie A. Hatcher, Frances Wasserman, Lisa Smith, Salley Jessee, Mark E. James, Beth Seelig,    An Empirical Study of the Psychodynamics of Suicide, Journal of American Psychoanalytic Association, vol. 46. 1998, pp. 777-796.

(41) Arthur Miller, After the Fall, act III.

(42) Safranek J. P., Autonomy and Assisted            Suicide, the execution of         freedom, Hastings Center Report, 28. no. 4. 1998, pp. 32-36.

(43) Vasilios Gioultsis, Euthanasia and socio-moral incidences. Annals 2-3, 1999- 2000, 2000-2001, St John Damascus Institute of Theology, University of Balamand, pp. 65-76 (in Greek).

(44) Jos Welie, The Medical Exception: Physicians, Euthanasia and the Dutch Criminal Law, The Journal of Medicine and Philosophy 17, no. 4, 1992, pp. 419-437,

(45) Mark D. Sullivan, Linda Ganzini, Stuart Younger, Should Psychiatrists Serve as Gatekeepers for Physician-Assisted Suicide?, Hastings Center Report July-August 1998, 24-25.

(46)Cassel E.J., Reactions to physical illness and hospitalization. In: Psychiatry in General Medical Practice, (eds): Usdin G. & Lewis J. M. New York McGraw-Hill, 1979, pp. 103-131.

(47) Cassel E.J., The nature of suffering and the goals of medicine, New York, Oxford University Press, 1991.

(48) Mt 25, 31-46.

(49) Mt 25, 40.

(50) John Chrysostom, The Divine Liturgy of St John Chrysostom, Holly Cross Orthodox Press, Brookline, Massachusetts, USA.

(51) Jacobus Goar, «Ακολουθία εις Ψυχορραγούντα», Officium Agentis Animam, in: Euchologion, cive Rituale Graecorum, Akademische Druck-u. Verlags anstalt, Graz, 1960, pp. 585-588.

(52) Spyridon Kontogiannis, Suicide and the Orthodox Church’s stance,  «Truth» («Alitheia», journal of the Christian Orthodox Church of Greece – offprint), January year B-25o, vol. 11, Athens, 2001, pp. 1. 8-9.

(53) Clement of Alexandria, Library of the Greek Fathers and Ecclesial Writers, Apostolic Diakonia of the Church of Greece, Athens, (ΒΕΠ) 1965, 8, 56, 39 (in Greek).

(54) Voulgarakis E., Suicide and Ecclesial burial, Armos, Athens, 1992 (in Greek)

(55) Abba Pahomios, Library of the Greek Fathers and Ecclesial Writers, Apos­tolic Diakonia of the Church of Greece, Athens. (BEI1) 1965, 41, 17, 14 (in Greek).

(56) Timothy of Alexandria, Library of the Greek Fathers and Ecclesial Writers, Apostolic Diakonia of the Church of Greece, Athens, (ΒΕΠ) 1965, Question 14, 42, 322, 4-15 (in Greek).

(57) Cummings D., Concerning Timothy of Alexandria, Question xiv, The Rudder (Pedalion), ed: The Orthodox Christian Educational Society, Chicago. Illinois, USA, 1957, p. 898.

(58) Konstantinos Rallis, Manual of Ecclesial Law, Athens, 1927, vol. 1, p. 142, (in Greek).

(59) Proctor R.N.,  Racial Hygiene, Cambridge, MA, Harvard University Press,

1988.

(60) Paul Chodoff, Misuse and abuse of Psychiatry: an overview, in: Psychiatric Ethics, eds S. Bloch, P. Chodoff, S. A. Green, Oxford University Press, Oxford, 1999, p. 61.

(61) George Kapsanis, The Pastorial Diakonia according to the Holy Canons, ed. Athos, Piraeus, Greece, 1976, (in Greek).

(62) Isidore the Pelusian, Patrologia Cursus Completus, Series Greca (PG). ed. Migne J.P., 78, 1504B (in Greek).