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Bioethics is a field that has defined itself in moral controversies. For example, bioethics has emerged as a discipline in the attempts to resolve moral controversies surrounding medical practices and health care policies in areas such as experimentation and research, abortion, reproduction, and the allocation of resources in health care. One source of constant moral controversy has been the issues surrounding death and dying. There have been controversies about the definition of death, the extent of the obligation to treat the dying, the use of resources for the care of the dying, euthanasia, and assisted suicide. From the celebrated cases in the United States of Karen Ann Quinlan and Nancy Beth Cruzan to the ruling on assisted suicide in the state of Washington (see, Compassion in Dying) the controversies of death and dying have been part of bioethics and public policy.

In the debates over moral issues in death and dying terms like “sanctity of life,” “respect for life,” and “human dignity” have been deployed often. These terms have been appealed to as men and women have sought to create public policy and develop moral consensus in the controversies of death and dying. Such terms are often used as the final court of appeal to justify particular moral choices or public policy in health care. Yet such terms are often heterogeneous in their meaning. Each of these terms is filled with enough ambiguity so as to bring together a wide range of hopes, images, feelings, and values that make the meaning and use of the terms very different. As a consequence people can appeal to the same term and draw very different conclusions about what should be done. In the case of Nancy Beth Cruzan one finds different parties in the controversy holding very different opinions about the case and yet each appeals to the concept of “sanctity of life.”

In this essay I want to examine, in a limited way, some of the different meanings of these terms. The first section of this paper will examine how terms such as sanctity of life are used within different religious traditions. In the second section I will outline how some have tried to use these terms in general, secular bioethics. It will be argued that as these terms are progressively excised from their religious or other specific context they become so ambiguous as to be meaningless. I will illustrate this point by examining the use of such terms in the case of Nancy Beth Cruzan. The principal argument of this presentation will be that terms like sanctity of life and respect for life can only be understood within the context of a moral framework and language. When excised from such frameworks the terms become incapable to direct health care policy in secular, morally pluralistic societies and they ought to be discarded.

1 Religious Perspectives and the Sanctity of Life

One finds terms such as “sanctity of life” and “respect for life” used in different religious traditions. The assumption is often made that the terms are more or less equivalent in meaning. However, after examining how either of these terms are defined within a tradition it becomes clear that they are not interchangeable. While they may have a family resemblance one will not, necessarily, draw the same conclusions from their different uses in different traditions. In the Christian view it is God who is the source of life’s sanctity and human life has a unique role in the created world because of its relationship to God. This view, focused on human life, is quite different from the Buddhist view that all life is intrinsically sacred. Indeed one finds that even within different religious traditions the terms take on different meanings. A consequence of such ambiguity in meaning, within and between moral traditions, is that terms like “sanctity of life” often convey very different meanings and justify different choices of action.

1.1 A Christian Perspective

While different meanings can be associated with “sanctity” the meaning that seems central to the term sanctity of life is the meaning of “being hallowed or sacred.” This definition conveys the notion of inviolability which is what the Latin root of sanctity (“sanctitas”) means. In the Christian tradition the claims about the sanctity of life seem to communicate the supposition that human life has an inviolability or a sacredness. One function of the claim that human life is sacred is to direct our actions. This claim of sanctity put limits on what can be done (e.g., human life ought not be taken) and makes demands on what should be done (e.g., life ought to be preserved). It is true that a fundamental and traditional concern of Christianity has been a concern not to harm human life. For example, The Didache, which dates to the first century, enjoins Christians: “[T]hou shalt not procure abortion nor commit infanticide” (Didache I 1965). It also condemns the murder of children (Didache V).Footnote 1 While traditional Christianity has held specific prohibitions against killing, it is too much to claim that these prohibitions form a doctrine of the sanctity of life. Joseph Boyle has argued that the phrase “sanctity of life” represents a family of values that is rarely articulated carefully even in the Christian tradition (Boyle 1989). Two themes seem to be interwoven in the Christian uses of “sanctity” when talking about human life. The first theme is that such life is holy because life is a gift from the Holy. In Christianity the origin of human sanctity is God. Life is a gift from God, who is Life, to human beings. However, this alone does not explain the Christian tradition insofar as all life is a gift from God and yet human life has a unique place in the created world. A second theme, or necessary condition, is that human life must have a special relationship with the Divine that sets human life apart from other forms of created life.

The uniqueness of human life, for Latin Christianity, has been explored in reflections on man as the “imago Dei” (Genesis 1:26). That is, human beings are made in the image of God. The Fathers of the Church were influenced by the view of the Old Testament that emphasized God as both the beginning and the destiny of man. Since all life is created, what is it that distinguishes human life as “sacred?” Human life has a “unique” status in that God impresses onto the human person God’s own image and resemblance and therefore makes the human being above other beings which are God’s creatures but not mirrors of the Creator. Human beings are part of the creation but they are distinguished from the rest of the creation as they are to rule as God rules. All life, since it comes from God, has a sacredness about it and demands respect, for it belongs to an-Other. The special dignity and sanctity of human life comes from bearing the image of God and the responsibility to rule like God.

The divine is expressed in the world in the human. Irenaeus best captured this patristic sense when he wrote: “Gloriam enim Dei vivens homo, vita autem hominis visio Dei” (Irenaeus 4. 20. 7 1979). The glory of God is the living human and the life of the human is the vision of God. The “glory of the human” is not a modem sense of self-improvement but the expression of the Divine in the human. Human life is made “holy” and endowed with “sanctity” and “dignity” because of its relationship to God.

Throughout the history of Christian theology and spirituality the meaning of human sanctity and dignity has been developed in different ways. For example, in the reflections of twelfth and thirteenth century Latin theologians there is a search to identify the characteristics that distinguished human life from all other forms of bodily, created life.

The epoch of scholastic philosophy was characterized by an emphasis on the intellectual and rational dimension of God’s image impressed onto the human. The expression “imago in specula rationis,” commonly used by scholastic thinkers, manifests this view. The pivotal point in this interpretation is that human sanctity consists in the human ability to know himself and God. The faculties of intellect and will, unique to man in the embodied, created world, were seen as the most divine of human attributes.

In contrast, theologians in the twentieth century have sought a less rationalistic and more balanced, integrated view of the human person. Many theologians have sought to develop a Christian anthropology that situates the rational within the relational and social context of human life (Rahner 1968; Schotsmans 1991; Wojtyla 1979). In contemporary Latin theology one finds that these two conditions for sanctity of human life have often been blended together under a theme of “stewardship.” As life is a gift and since it is a gift with a purpose, one is called to be a good steward of the life given. The two conditions for the sanctity of human life lead to different moral imperatives. First there are proscriptions against the taking of innocent human life. For example, according to the Roman Catholic tradition innocent human life can not be directly, intentionally taken. Thus there are proscriptions against suicide, abortion, and murder. At the same time the tradition has reflections not only about the protection of life but that it should be used well. Archbishop Daniel Cronin writes: “Among the natural gifts with which the Most High God have favored man, there is none so excellent as that of life, because it is life that is the basis for all else that man has or can hope to attain” (Cronin 1958, 3). In this vein there are serious and prolonged reflections on the positive obligation to preserve life insofar as it is a basis for achieving other goods (see Cronin 1958).

As one examines particular moral questions surrounding death and dying one discovers that the term “sanctity of life” has contributed very little to their discussion in the Christian tradition. Issues about suicide and euthanasia have been treated by the prohibition against the direct, intentional taking of innocent human life. The questions about the obligation to preserve life by pursuit of life-sustaining treatments have been addressed by the distinction of ordinary and extraordinary means. Questions about the definition of death have been addressed by discussion of the metaphysical questions of hyelemorphic composition and whole brain death. In no one of these areas has the term “sanctity of life” contributed to the substantive discussion. Rather, the term seems to have emerged more in secular discussions of bioethics and in the abortion debate (see Brody 1975).

1.2 Buddhist Perspectives

The ambiguities in terms like “sanctity of life” are made ever more clear when one contrasts a Christian tradition with other religious traditions. In Buddhism the first of the Grave Precepts is to “affirm life; do not kill.” The principle of respect for life, as it has been called, is one of the foundations of Buddhist ethics (Fujii 1991). It has been the basis for a clear-cut position against practices such as abortion (Nolan 1993, 194; Stevens 1990, 138–139). However, in Buddhist thought the principle of respect for life must be understood within the context of other aspects of Buddhist teaching as well as the other precepts. Different traditions within Buddhism balance the concern for respect for life with concern with doing “the most compassionate action” (Nolan 1993, 194). So while there is a general prohibition against a practice such as abortion, for example, such particular decisions must be made within the context of the other elements of suffering and with a view toward compassion. A decision to violate the first precept is one that should not be taken lightly but to fail to violate it, when compassion demands, it is to generate negative karma (Kaplean 1981, 228; Rinpoche 1992, 376). One finds then that the precept of respect for life needs to be interpreted within the framework of the situation and other moral demands. One also finds that the different traditions of Buddhism will make different interpretations of how to deploy the Precept.

In addressing the questions of treatment decisions at the end of life one finds different interpretations of the first precept. For some Buddhists following the first precept means to utilize whatever means of treatment and recovery are available. The argument is that human life offers an opportunity to transcend suffering through enlightenment and there is the possibility for every disease to be cured as long as life continues (Ratanakul 1988, 310). However, the Buddhist discussion of the issue needs to balance the first precept to respect life with the demands of suffering and compassion. Treatment cannot be refused simply to escape suffering but one can refuse treatment for selfless and compassionate reasons. That is, a person may refuse treatment to act compassionately towards family and friends, or to relieve burdens (e.g., economic) on them.

One finds similar sets of issues and themes arising in discussions of active euthanasia.Footnote 2 Those who disapprove of forgoing treatment in that it has the character of suicide or “death-seeking” oppose active euthanasia (Nolan 1993, 199). Yet, as one might expect, those who allow an exception do so because they appeal to compassion. What is crucial for my argument is that the precept of “respect for life” is balanced with compassion and it is this balancing that helps determine the significance of the precept. This balancing only takes place within the context of a tradition.

1.3 Summary

This brief overview illustrates how terms like sanctity of life or respect for life have been understood within different moral narratives. In the Christian tradition human life is sacred because it bears the divine image, while in Buddhism human life is sacred because all life is sacred. However, what is perhaps most instructive for general, secular bioethics is that even within these narratives there are ambiguities in understanding these terms in light of particular moral choices. As one examines the use of such terms, these ambiguities offer a warning for secular bioethics. These terms, which are difficult to define within a moral tradition, will take on so many meanings in general, secular discourse as to become meaningless. The Cruzan case illustrates how people with very different views of moral controversies in death and dying can reach very different conclusions by appealing to the “sanctity of life.”

2 Bioethics and Sanctity of Life

2.1 General, Secular Bioethics

Discussions of sanctity of life seem to have entered the English bioethics literature in the early 1950s.Footnote 3 In 1957 one finds Glanville Williams using the term “sanctity of life” in some of his jurisprudential writings (Williams 1957). The use of the term initially centered around issues such as euthanasia and abortion. In criticizing the legalization of voluntary euthanasia John Bonnell argued that Christianity has emphasized “the sanctity of human life and the value of the individual, even the humblest and lowliest, including the afflicted in mind and body” (Bonnell 1951). The article by Bonnell was in part a response to an essay by Joseph Fletcher in which Fletcher argued for the centrality of persons over mere life. Fletcher argued that one would be better served to speak of the role that persons have in deciding for themselves rather than to appeal to principles like “sanctity of life” (Fletcher 1951).

In 1964 Norman St. John-Stevas argued that the Christian attitude toward euthanasia is based on “the principle of the sanctity of life” (St. John-Stevas 1964, 43). In these early uses of “sanctity of life” in bioethics there are clear religious (particularly Christian) presumptions (Ramsey 1967). Harmon Smith, in a commentary on Paul Ramsey, speaks of the religious framework within which the notion of sanctity of life was understood (Smith 1970). He writes:

… the question of when sanctity attaches to human life is not religiously problematic at all (for Ramsey): “One grasps the religious outlook upon the sanctity of human life only if one sees that this life is asserted to be surrounded by sanctity that need not be in a man; that the most dignity a man ever possesses is a dignity alien to him … A man’s dignity arises from God’s dealings with him, and not primarily in anticipation of anything he will ever have it in him to be.” (Smith 1970, 42)

Sanctity of human life for Ramsey and other Christians is derived from the fact that God values human beings.

There have been some attempts in bioethics to give the principle of the sanctity of life a less religious significance. One example is the work of Daniel Callahan in his exploration of abortion. Callahan understands the problem with using a religious term like sanctity of life in a secular society. In his attempt to give sanctity of life a secular meaning Callahan writes: “An affirmation of the sanctity of life which required that one accept a religious view of man’s origin would provide a weak base upon which to build a consensus. One then would seem to be saying that there is nothing whatever upon which to ground the sanctity save that of religious belief….” (Callahan 1970, 315). Callahan attempts to use the content of religious, particularly Christian, views without their theological foundations. This analysis and transformation leads Callahan to understand the sanctity of life as an affirmation of a morality that affirms “the protection and preservation of human life, both actual and potential” (p. 343). Callahan articulates a diverse collection of rules gathered under the rubric of the term sanctity of life. These include: “(a) the survival and integrity of the human species, (b) the integrity of family lineages, (c) the integrity of bodily life, (d) the integrity of personal choice and self-determination, mental and emotional individuality and (e) the integrity of personal bodily individuality” (p. 327). While he recognizes the ambiguity of the term, Callahan still attempts to derive from it some useful direction and moral sense.

K. Danner Clouser, in 1972, criticized the term “sanctity of life” for this very ambiguity. He argued that all the different meanings, and their implications, are mixed together. Clouser wrote: “I find the sanctity of life concept to be impossibly vague and to be a concept that is inaccurate and misleading, whose positive points can be better handled by other well-established concepts” (Clouser 1973, 119). William Frankena, in 1975, sorted out the different meanings that are gathered under the term sanctity of life.

  1. 1.

    The sanctity of bodily human life should be distinguished from that of individuality or personality. The sanctity of human life (bodily) is relevant to the discussion of questions of shortening or preventing human life.

  2. 2.

    Mere life, whether that of a vegetable, animal, or human organism, has no moral sanctity as such, though it may have aesthetic and other kinds of nonmoral value, and may be a necessary condition of consciousness, rationality, or morality.

  3. 3.

    Life has moral sanctity, but only where it is a condition of something more, as it is in human fetuses.

  4. 4.

    There is something inherent – consciousness, feeling, reason – in such living beings.

  5. 5.

    Even if the moral sanctity of human life (bodily) is not absolute, it is considerable, at least from the moral point of view, but it is only prima facie or presumptive.

  6. 6.

    The only tenable view, then, is a derivative, qualified, and noncomprehensive ethics of respect for life (Frankena 1977, 58).

Frankena’s work points out the ambiguity of terms such as “sanctity of life” and “respect for life.” His work also points out the conceptual problems with deploying such terms in a general, secular bioethics. In the midst of all these different accounts of these terms there is no way, in a general secular context, to pick out which is the correct interpretation. General, secular bioethics runs the risk of speaking in babel when terms like “sanctity of life” and “respect for life” are used. Indeed the case of Nancy Beth Cruzan, and the general issues of death and dying, make this babel very clear.

2.2 Cruzan: An Example

Despite the ambiguities in the term it has played a crucial role in certain controversies in bioethics about decisions at the end of life. The Missouri Supreme Court, for example, in its decision in the Cruzan case asserted that the protection of the “sanctity of life” was a state interest such that the state should prevent the withdrawal of feeing and hydration (Cruzan v. Harmon).

The case involved a patient who had been in a persistent vegetative state since an automobile accident. As she was anoxic for 12–14 min, Mary Beth Cruzan suffered irremediable brain damage. Subsequent to the accident a gastrostomy feeding and hydration tube was placed with the consent of her husband. When it became clear to her parents that their daughter had no chance of recovery, they sought removal of the tube. The employees of the hospital refused to comply with the request. The Supreme Court of Missouri, in a divided opinion, denied the parents’ request. The state argued that there was a state interest in the sanctity of life under the parens patriae doctrine of common law (Payton 1992). For this essay it is important to note that the State Supreme Court, as well as several opinions of the U.S. Supreme Court upheld “sanctity of life” as a value which trumps other values. The Missouri Supreme Court wrote:

The State’s interest in life embraces two separate concerns: an interest in the prolongation of the life of the individual patient and an interest in the sanctity of life itself. (Cruzan 1988, emphasis added)

In the view of the majority, these general interests are strong enough to foreclose any decision to refuse treatment for an incompetent person unless there exists clear and convincing evidence that the person previously had made such a choice.

While asserting sanctity of life as a value that orders other values, its meaning is never made clear nor is there an argument as to why this value should trump other values. The opinions of the justices in these decisions, in fact, reflect a pluralism of moral vision and language. Indeed, Justice Stevens, of the United States Supreme Court, in his dissenting opinion in the appeal of the case, pointed out that: “Life, particularly human life, is not commonly thought of as a merely physiological condition or function. Its sanctity is often thought to derive from the impossibility of any such reduction” (Cruzan 1990, Stevens’ dissent, Part III). Stevens’ dissent represents a very different interpretation of sanctity of life from the one deployed by the State Supreme Court. For Stevens, and others, the sanctity of human life is centered on the capacities of personhood. In a sense Stevens’ view is not far from the view of Medieval theologians who focused on the rational capacities as the essence of the divine image in the human. The loss of these capacities ends the obligation to sustain life.

The different interpretations of the nature of the “sanctity” lead to very different outcomes of the case. Stevens captures the difficulty of using terms like “sanctity of life.” He points out “the more precise constitutional significance of death is difficulty to describe; not much may be said with confidence about death unless it is said from faith, and this alone is reason enough to protect the freedom to conform choices about death to individual conscience” (Cruzan 1990; Stevens’s dissent, Part III, emphasis added). Indeed one sees in the Cruzan case two different appeals to sanctity of life. One appeal interprets the term to require aggressive medical treatment so that she can be kept alive. The other interpretation concludes that the treatment should be withheld.

3 Conclusion

The argument of this paper has been that terms like “sanctity of life” are so ambiguous that they can support starkly contrasting choices in the treatment of the dying. Outside the context of a particular moral community or moral narrative the principle of sanctity of life can be interpreted in at least the following ways:

  1. 1.

    The principle of the sanctity of life requires one to save human life at all costs.

  2. 2.

    The principle of sanctity of life requires that one preserve the values associated with human life and these can be jeopardized if one tries to save mere biological life.

In the second interpretation sanctity of life is not to be achieved simply through biological life, but through a self-conscious moral life. This is the interpretation that lies behind the traditional Roman Catholic distinction of ordinary and extraordinary means (Wildes 1991). There is a recognition that if one makes the mere prolongation of life an overriding good, the place of other moral goods will be disturbed (Pope Pius XII 1958). The difficulties with appeals to terms like “sanctity of life,” “respect for life,” or “human dignity” is that they are more like slogans than principles outside of a particular context. I have argued that such terms can be understood within the language of a moral community. Excised from such communities such terms become ambiguous and useless. That is, they bring together a number of issues and attitudes more than set out foundations or rules for choices. People with very different views rally around them. It becomes impossible to establish a canonical interpretation of the principle of the sanctity of life. Indeed if one looks at the Latin Christian tradition it is clear that “sanctity of life” has not been understood as a moral principle. Rather, one might see it as a background assumption that shaped moral principles such as the prohibition against directly intending to take human life or the distinction of ordinary and extraordinary means. It is only in recent years, in debating issues of death and dying, that such terms have been invoked and used as principles. However, as I have argued, when such terms are taken from their basic role they yield very little. The result is more like babel than language.