**4. The quality of life from a theological perspective**

Sufferance leads to a crucial question: is there life after death? Does sufferance have any meaning in relation to the transcendent? Even if medicine argues that sufferance can be controlled and death postponed, eventually death wins. Supporting euthanasia these days is like Seneca's pagan stoicism expressed in his letters on suicide: "One death involves pain, another is simple and easy, why not take the easy one?" [9]. It is known that Seneca, to avoid being captured and tortured by Nero, commits suicide together with his wife. In the current secularised society, which encourages self-determination in an exacerbated way – with individuals no longer observing any moral principle – the intention is that religion should encourage active voluntary euthanasia and medically assisted suicide. In other words, Christians should be encouraged to avoid sufferance and choose death as great dignity. This is how the commercials that encourage these suicidal acts have appeared: "The Death Club: leave this life with the same spark you have lived it", "The last journey: experiment death that you have always wanted! Leave in dignity, pleasure and style!" or "Executive death: for those who have always been in control" [6].

Through biotechnology, the life expectancy has increased but the 21st century's individual "lives a spiritual crisis, namely a crisis of significance because they want to maximize happiness in this earthly life, seeking to transform the biological in the search for perfection" [10]. The Church expressed its concern that genetic research is not closely monitored and regulated to ensure the protection of the community [10]. The Romanian Orthodox Church has initiated an action, by setting up in 2001 certain Bioethics Committees that debate litigious themes where the faith in life's Sacrality is expressed, as well as in human dignity and its individuality [11]. There needs to be an open dialogue between researchers (laic people) and the representatives of the Church regarding the implications of genetic technologies: "The determination of a relationship between science and religion should seek common points in time to observe the gap between metaphysics and epistemology. Hence, the importance of initiating a dialogue between religion and science by means of Bioethics" [11].

The influence of evil on those in pain is often remembered in theology. Thus, in the case of St. Martyrs Timotheus and Mavra who were in the ordeals of death, the devil showed to them under an angel's face to allegedly save them from sufferance; however, his presence was meant to take from them the crown of martyrdom [12]. Although individuals suffer with their body, the temptation addresses the soul, because the "soul is the vital principle of the body – the one that gives it life, structures, puts it into motion and keeps it alive [13]. Unfaithful people are afraid of death while the faithful see death as a "gate to eternal life" [14], death "not being evil in itself, what would be bad is to die badly" [15] as St. John Chrysostom says, namely unprepared for eternity. "The world, in its entirety, as well as each thing created by God, has a rationality, they were created for a reason and towards a certain finality" [16]. "The physical world, aware or not of God's love, is created as a means of His love for humans" [16]. Christian theology speaks about the *necessity of sufferance*. Saint Isaac the Syrian argues that sufferance "is necessarily useful to people. For the sinful for humbleness and return from sin while for the more spiritually advanced to strengthen them and help them move forward towards

*Bioethics in Medicine and Society*

the *secular* one.

**3.1 Christian or secular bioethics**

Orthodoxy states that the divine teaching came to us through individuals inspired by God, who prepared themselves in fasting and prayer before conceiving laws for people. Due to human pride and vanity, the European started making laws for humans that adapt to the times, without considering the laws given by God to humanity through *chosen* and *inspired* people. That is why we have come to the *multitude of opinions* regarding how the world can be led to reach happiness and wellbeing. This desire for happiness was not related to heaven, though, being directed only towards Earth, with its finitude here. Thus, a new type of moral appeared from the benches of rational academies, which was applied in the human society, at the beginning in as many "morals" as opinions there were, later unified in a single moral,

Christian bioethics argues that life begins at conception and that starting with the zygote, there is a human being in the making, which needs to be treated as such. Reporting human life to eternity, Christian bioethics defends the embryo, acknowledging its soul. Christians do not "raise the problem of the embryo just for fun but reach it starting from the resurrection" [8] but still, they are different in thought. Tristam Engelhard was wondering, "which Christianity is better for a Christian bioethics?", answering that "we should see Christianity from a historical perspective, in the sense that it is at the basis of the historical roots of contemporary Christianities, or that we should see it not like something from the past, old and obsolete, but as something present, animated and alive" [6]. In the West, theology went towards aggiornamento, meaning that the accent transferred on the "accommodation" with the world, while in the East, orthodox Christianity kept the tradition, the accent being placed on sanctification of the world. The aggiornamento of theology has decisively influenced bioethics, which in turn became "accommodated" with the worldly, immanent interests to the detriment of the transcendent. There arises thus a dispute between bioethics built on the grounds of the transcendent Divine Revelation and bioethics built on the grounds of immanent human rationality. In the context of secular moral there also appears the *principle of permissiveness* which is a procedural one. This principle "will justify, support and explain moral practices based on procedures, such as the rights and contracts, to give up on what we are entitled to (forbearance rights and contracts), including contracts for health care services. The principle of permissiveness will be central not because it would be valued, but because the people's permission is the only accessible source of secular authority. In the absence of a canonical ethic, the bioethics of such a society will prioritize certain practices such as informed consent, the right to refuse the treatment, the development of contracts for health services and the right to do to oneself and to the others who consent as it was mutually agreed upon (for instance, a doctor assisted suicide or euthanasia)" [6]. Kierkegaard states that "Christian bioethics should never become a matter of academic erudition" [6]. As it is impossible to talk about love if one does not love, about the good if one does no good or about forgiveness if one does not forgive. The good that God wants for us differs from the good we want, as humans. Transcendent good differs from the immanent good. In transcendental terms, the "good" of a medically assisted suicide becomes "evil" and in immanent terms, the "evil" of human sufferance becomes a "good" performed through euthanasia. In the absence of transcendental communication, sufferance acquires extreme dimensions in the immanent world, which is why it is put to an end by medically assisted suicide. "In transcendental Christianity, the accent falls on experiencing God, which implies the content of moral life (including what is related to health care (…) therefore, Christian bioethics should be more of a lifestyle

**8**

being God-like" [16]. The soul, in orthodox conception, is created simultaneously with the body at conception and, "once created, the soul is characterized by immortality, that is it will not die, but be reunited with the body at the resurrection of the dead" [17]. Saint Irine draws a distinction between eternity and immortality, arguing that "eternity should not be understood as an endless space in time, but rather as a *quality of the being*, in permanent communion with God. On the other hand, immortality involves the suspension of death, its annihilation" [17]. From here we infer that the *quality of life into Christ* is essential when reporting to immortality, eternity. It is only in this *key* that sufferance and death appear as a blessing and not as punishment. We cannot say that when a doctor prescribes a bitter drug, they want to punish us, so this is how sufferance and death should be understood, as allowed by God. It all reports to eternity, that is why the Church encourages and prays for those in sufferance to bear it until the end, when God decides their fate for eternity. "As much as you would pray, do not use the prayer as you use sufferance, because in all troubles hides a great secret, for God knows about people's suffering and allows it" [18].

### **4.1 Case study: euthanasia versus palliative care**

The "treatment" through euthanasia or medically assisted suicide is expressed using various euphemisms, such as "to put down out of mercy", "gentle death", etc. which brutally enters a human being's life (body and soul), putting an end to the body's pain but failing to consider spiritual values. Several factors account for the patient's sufferance, such as the emotional, physical, and emotional factor. Euthanasia only "solves" the physical factor. With an honest palliative therapy, that approaches all determining factors (including the psychic and spiritual ones), the patient's emotional state is modified, and the quality of life acquires a whole new meaning. The justification of euthanasia starts from the following premises: the individual has a right to die and the value of human life is measurable, human life can be approached as animal life, sufferance cannot have any beneficial function, the request for euthanasia is always rational and trustworthy, the medical diagnosis and prognosis are always certain, the degree of an individual's sufferance can always be realistically appreciated, the efficient alternative methods to alleviate sufferance are nowhere to be found and euthanasia is a justified duty of the doctor. If we study the premises for the practice of euthanasia, we see they have a doubtful value, especially those of a medical nature. Initially, euthanasia was approached only in case of incurable patients, to put a stop to their suffering, but it then took a turn for the worse, when the old, the handicapped, invalids, chronic patients, depressive patients, children and newly-born with malformations became vulnerable. Three out of four paediatricians are trained in euthanizing children and newly born [19].

Euthanasia has been made legal in many states, but the law is extremely unclear and imprecise in the countries that accept it. As an example, the term "terminal suffering" is not clarified. The word "terminal" is not mentioned, and euthanasia can be applied in non-terminal cases, as well. That happens in 15% of the cases. Only physical and psychic sufferance are stipulated. Since the law is unclear, it has come to be applied in a larger and larger context. Furthermore, it has been assessed that euthanasia is delegated more and more often to nurses, while normally only the doctor is allowed to carry it out. It has been assessed that the effect of the law is not to provide people with enough support in life. People are suggested to resort to euthanasia, although that was not their initial thought. Euthanasia can be asked by people with poor sight who do not want to wear glasses, because the law allows it. To practice euthanasia is, by excellence, a problematic act. In Netherlands, but

**11**

*The Quality of Life in the Light of Immanence and Its Sacrality in the Light of Transcendence*

in other states as well, euthanasia no longer applies to people in terminal cancer or with Alzheimer, but simply to anyone who "has had enough of life". It came to be used in case of children, which is particularly serious. This "service" can pe performed "at the client's address". It may be asserted that, once legalised, euthanasia can no longer be kept under control. The law stipulates that any euthanasia should be reported with the authorities, but those who carry it out argue that it is a "waste of time" and "boring bureaucracy". The introduction of the presumed consent is being attempted. These events trigger a movement *against euthanasia*, based on the

a.Euthanasia is too radical. It destroys a problem instead of solving it. By putting an end to the patient's life, it deprives them of any hope and of any possibility

b.Euthanasia has not ethical justification. There is an ethical principle of totality that allows the sacrifice of a part for the sake of the whole. There is no reverse principle – to sacrifice the whole for the sake of a part. Certainly, that would be

c.Euthanasia is difficult to put in practice. The various schemes of euthanasia suggest that euthanasia will be performed by doctors. Nevertheless, doctors are trained to preserve life, not to destroy it. Probably there will not be too many doctors who want to be known as the executioners of their patients, since that

d.Euthanasia becomes less and less necessary. When the ideas supporting

Oncologist David Cundiff shows in his book, **"**Euthanasia is not the right answer" that: *"Uncontrolled pain and suffering are on top of the list for the euthanasia request".* Many patients who suffer excruciating pains have proper medical insurance that offers them access to pain control medication or brain surgeries that led to the disappearance of the perception of pain. He underlines that with the legalisation of euthanasia, "*the right to die will become the duty to die".* Accusations of the type – "*the most vulnerable"* people *"are under the assault of euthanasia practitioners"*, and families need to cope with "*anti-life assaults on the loved ones*" which "*threaten the lives of the* 

Now, there is a better solution than euthanasia, and that is caring for the human being. Palliative care is the active and global medical care for patients for whom any other treatment fails to work. It is important to bring attention to the fact that the end of life usually occurs slowly and naturally. A palliative care covers all, from a dying child to family, brothers, sisters, all those involved in their life, because after a child dies, the others remain here. *All patients who request euthanasia should mandatorily be offered palliative care first*. Then they will see that the desire to die disappears most of the times when physical sufferance is diminished and when emotional support is offered. There is always a possibility of finding the good, the quality of life, of finding a purpose, even for the sick and disabled. Regardless of a disease an individual might have, loss of autonomy does not equal loss of dignity" [20].

euthanasia were launched, the concept and practice of palliative medicine were unknown. The doctors had no practical guides and no experience in analgesics and in eliminating other unpleasant symptoms caused by incurable diseases. With an efficient approach of several bothering symptoms, with the development of psychiatric facilities and healthcare units, the necessity for euthanasia

would undermine their doctor-patient relationship.

*DOI: http://dx.doi.org/10.5772/intechopen.93584*

of regret or change of hearts.

illogical and non-ethical.

has drastically lowered.

*medically vulnerable*" – are more and more frequent.

following arguments:

#### *The Quality of Life in the Light of Immanence and Its Sacrality in the Light of Transcendence DOI: http://dx.doi.org/10.5772/intechopen.93584*

in other states as well, euthanasia no longer applies to people in terminal cancer or with Alzheimer, but simply to anyone who "has had enough of life". It came to be used in case of children, which is particularly serious. This "service" can pe performed "at the client's address". It may be asserted that, once legalised, euthanasia can no longer be kept under control. The law stipulates that any euthanasia should be reported with the authorities, but those who carry it out argue that it is a "waste of time" and "boring bureaucracy". The introduction of the presumed consent is being attempted. These events trigger a movement *against euthanasia*, based on the following arguments:


Oncologist David Cundiff shows in his book, **"**Euthanasia is not the right answer" that: *"Uncontrolled pain and suffering are on top of the list for the euthanasia request".* Many patients who suffer excruciating pains have proper medical insurance that offers them access to pain control medication or brain surgeries that led to the disappearance of the perception of pain. He underlines that with the legalisation of euthanasia, "*the right to die will become the duty to die".* Accusations of the type – "*the most vulnerable"* people *"are under the assault of euthanasia practitioners"*, and families need to cope with "*anti-life assaults on the loved ones*" which "*threaten the lives of the medically vulnerable*" – are more and more frequent.

Now, there is a better solution than euthanasia, and that is caring for the human being. Palliative care is the active and global medical care for patients for whom any other treatment fails to work. It is important to bring attention to the fact that the end of life usually occurs slowly and naturally. A palliative care covers all, from a dying child to family, brothers, sisters, all those involved in their life, because after a child dies, the others remain here. *All patients who request euthanasia should mandatorily be offered palliative care first*. Then they will see that the desire to die disappears most of the times when physical sufferance is diminished and when emotional support is offered. There is always a possibility of finding the good, the quality of life, of finding a purpose, even for the sick and disabled. Regardless of a disease an individual might have, loss of autonomy does not equal loss of dignity" [20].

*Bioethics in Medicine and Society*

and allows it" [18].

newly born [19].

**4.1 Case study: euthanasia versus palliative care**

being God-like" [16]. The soul, in orthodox conception, is created simultaneously with the body at conception and, "once created, the soul is characterized by immortality, that is it will not die, but be reunited with the body at the resurrection of the dead" [17]. Saint Irine draws a distinction between eternity and immortality, arguing that "eternity should not be understood as an endless space in time, but rather as a *quality of the being*, in permanent communion with God. On the other hand, immortality involves the suspension of death, its annihilation" [17]. From here we infer that the *quality of life into Christ* is essential when reporting to immortality, eternity. It is only in this *key* that sufferance and death appear as a blessing and not as punishment. We cannot say that when a doctor prescribes a bitter drug, they want to punish us, so this is how sufferance and death should be understood, as allowed by God. It all reports to eternity, that is why the Church encourages and prays for those in sufferance to bear it until the end, when God decides their fate for eternity. "As much as you would pray, do not use the prayer as you use sufferance, because in all troubles hides a great secret, for God knows about people's suffering

The "treatment" through euthanasia or medically assisted suicide is expressed using various euphemisms, such as "to put down out of mercy", "gentle death", etc. which brutally enters a human being's life (body and soul), putting an end to the body's pain but failing to consider spiritual values. Several factors account for the patient's sufferance, such as the emotional, physical, and emotional factor. Euthanasia only "solves" the physical factor. With an honest palliative therapy, that approaches all determining factors (including the psychic and spiritual ones), the patient's emotional state is modified, and the quality of life acquires a whole new meaning. The justification of euthanasia starts from the following premises: the individual has a right to die and the value of human life is measurable, human life can be approached as animal life, sufferance cannot have any beneficial function, the request for euthanasia is always rational and trustworthy, the medical diagnosis and prognosis are always certain, the degree of an individual's sufferance can always be realistically appreciated, the efficient alternative methods to alleviate sufferance are nowhere to be found and euthanasia is a justified duty of the doctor. If we study the premises for the practice of euthanasia, we see they have a doubtful value, especially those of a medical nature. Initially, euthanasia was approached only in case of incurable patients, to put a stop to their suffering, but it then took a turn for the worse, when the old, the handicapped, invalids, chronic patients, depressive patients, children and newly-born with malformations became vulnerable. Three out of four paediatricians are trained in euthanizing children and

Euthanasia has been made legal in many states, but the law is extremely unclear and imprecise in the countries that accept it. As an example, the term "terminal suffering" is not clarified. The word "terminal" is not mentioned, and euthanasia can be applied in non-terminal cases, as well. That happens in 15% of the cases. Only physical and psychic sufferance are stipulated. Since the law is unclear, it has come to be applied in a larger and larger context. Furthermore, it has been assessed that euthanasia is delegated more and more often to nurses, while normally only the doctor is allowed to carry it out. It has been assessed that the effect of the law is not to provide people with enough support in life. People are suggested to resort to euthanasia, although that was not their initial thought. Euthanasia can be asked by people with poor sight who do not want to wear glasses, because the law allows it. To practice euthanasia is, by excellence, a problematic act. In Netherlands, but

**10**

Palliative care should be the answer to the question why euthanasia should not be resorted to, because this care implies bioethics, psychology, theology, etc. There is research which show that a significant percentage of those requesting euthanasia give it up once they sign up for a palliative care program. Certainly, the family plays the most important role [21] but together with the other actors of the palliative care, hope can be reached, a chance given for the patient's life to change, even if terminally ill. A lived hope may prove determining [22].

The first International Conference for Palliative Medicine Research (May, 1998, Bethesda, Maryland) organised by Dr. Russell Portenoy, the President of the "Pain Medicine and Palliative Care" Department within the Medical Centre Beth Israel in New York and by Dr. Eduardo Bruera, Director of the palliative care program within the "Grey Nuns" communitarian hospital (with the participation of 268 experts in palliative medicine from 22 countries) constituted the event that defined palliative care as a real an efficient alternative to euthanasia. In Romania, at Brasov, there is an organisation – The Medical Foundation Hospice "House of Hope" and a Centre for Palliative Care Medicine. These have organised Courses of Palliative Care in collaboration with the National Association of Palliative Care, which took the form of plenary presentations and workshops. Due to this activity, 43 institutions or sections of palliative medicine (public and private) were set up in the country.

The Christian orthodox church is against the legalisation of euthanasia. Still, the Christian orthodox church has a special prayer for those on the deathbed, which looks like a theological "euthanasia": "*the prayer of the hard separation from the soul*". The priest is called to the moribund patient's bed and, through his Godgiven grace expressed in this prayer, unties the soul from the moribund body to make it to eternity. *The prayer of the hard separation from the soul* (a prayer for the dying) is a prayer dates at least from the second half of the 4th century [23] and is given when an orthodox believer torments on the sufferance bed, unable to die peacefully. This is the solution of the Church for the prolonged sufferance issue: we ask God to put an end to sufferance by death, for Him to peacefully sever the soul of His servant from their body and rest them with the eternal and the saints. The effect of the prayer is beneficial for the moribund patient, namely that their soul leaving the body will have rested in heavens, beside God's saints. The priest prays for the moribund patient's soul: "*So Lord, God Almighty, hear me, Your sinning and unworthy servant at this hour and free Your servant from this unbearable pain and bitter powerlessness that has a hold on him and rest him with the souls of the righteous*…" [23]. Therefore, the purpose of this sermon that the priest performs by the moribund patient's deathbed is to free them from the body but, at the same time, to protect them from the powers of the demons, since "the demons cannot lead these souls to heavens" [24], but to hell. If, in case of euthanasia and medically assisted suicide, the action of ending the earthly life is carried out by a human being (the doctor, nurse, with or without the patient's approval, in this case of spiritual "euthanasia" the action is performed by God, following the priest's prayer. Only God decides the exit of humans from earth towards eternity. Only Him knows how much an individual still has to suffer to have access to the heavenly skies.

#### **5. Conclusions**

In a holistic approach, the quality of life means the relationship between the body and the soul, which only together can determine an individual's existence. According to this approach, separating and ignoring the value of the soul means to mutilate the individual, to wrong them, since joy and pain belong both to the body and to the soul. When the body is in excruciating pain, the soul is the one that

**13**

**Author details**

transcendence.

Ungureanu Mihail Adeodatus and Vasile Astărăstoae\*

\*Address all correspondence to: astarastoae@gmail.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

University "Grigore T. Popa", Iași, Romania

provided the original work is properly cited.

*The Quality of Life in the Light of Immanence and Its Sacrality in the Light of Transcendence*

comes to substitute this want of the body, strengthening and supporting it. But the soul can only do that if it receives help and this help can come from family and from society but, above all, the greatest help comes from Divinity, which is immanent and transcendent at the same time in relationship with His creation. It is transcendent by the fact that it cannot be known in Its being, but also immanent through the actions performed in the world, especially in the quality of humans' life. In the Christian orthodox theology, God help human through the soul to overcome these sufferings, offering them a happy living in His kingdom eventually. If God's work is ignored in the world, suffering really becomes atrocious and the individual, unable to take it anymore, commits suicide with the help of medicine, which should cure instead of murdering. That is why to legalise euthanasia under the pretext of the quality of life puts enormous pressure on the sick, the old and the disabled, who come to see themselves as a burden for the others and thus to feel morally constrain to accept death. The psychic sufferance of these individuals is fierce, as they feel useless and unloved, an economic burden for the relatives who must pay for an expensive treatment. On the other hand, by legalising euthanasia, social distress would be created, and there will be great changes in the social attitude towards sickness, infirmity, death and old age, in parallel with root modifications of the role of the medical profession. Human values, such as patience, compassion, solidarity, and commitment become void. Killing becomes a "treatment option", beside surgery, radiotherapy, chemotherapy, the treatment of pain or antidepressant medication. Palliative care may be undermined, and the doctor-patient relationships will be deteriorated. Modern medicine has the capability of reducing pain, even in the worst cases. Meanwhile, those who intent to extend their life by means of biotechnology want, in fact, to build a sort of earthly heaven for them, inventing all kinds of doctrines and utopias to believe that humans alone, without God, may achieve a perfect quality of life, here on Earth. The wellbeing and worldly riches they long for have nothing in common with the true quality of life, which also involves the soul. Instead of immanence versus transcendence, we opt for immanence together with

*DOI: http://dx.doi.org/10.5772/intechopen.93584*

#### *The Quality of Life in the Light of Immanence and Its Sacrality in the Light of Transcendence DOI: http://dx.doi.org/10.5772/intechopen.93584*

comes to substitute this want of the body, strengthening and supporting it. But the soul can only do that if it receives help and this help can come from family and from society but, above all, the greatest help comes from Divinity, which is immanent and transcendent at the same time in relationship with His creation. It is transcendent by the fact that it cannot be known in Its being, but also immanent through the actions performed in the world, especially in the quality of humans' life. In the Christian orthodox theology, God help human through the soul to overcome these sufferings, offering them a happy living in His kingdom eventually. If God's work is ignored in the world, suffering really becomes atrocious and the individual, unable to take it anymore, commits suicide with the help of medicine, which should cure instead of murdering. That is why to legalise euthanasia under the pretext of the quality of life puts enormous pressure on the sick, the old and the disabled, who come to see themselves as a burden for the others and thus to feel morally constrain to accept death. The psychic sufferance of these individuals is fierce, as they feel useless and unloved, an economic burden for the relatives who must pay for an expensive treatment. On the other hand, by legalising euthanasia, social distress would be created, and there will be great changes in the social attitude towards sickness, infirmity, death and old age, in parallel with root modifications of the role of the medical profession. Human values, such as patience, compassion, solidarity, and commitment become void. Killing becomes a "treatment option", beside surgery, radiotherapy, chemotherapy, the treatment of pain or antidepressant medication. Palliative care may be undermined, and the doctor-patient relationships will be deteriorated. Modern medicine has the capability of reducing pain, even in the worst cases. Meanwhile, those who intent to extend their life by means of biotechnology want, in fact, to build a sort of earthly heaven for them, inventing all kinds of doctrines and utopias to believe that humans alone, without God, may achieve a perfect quality of life, here on Earth. The wellbeing and worldly riches they long for have nothing in common with the true quality of life, which also involves the soul. Instead of immanence versus transcendence, we opt for immanence together with transcendence.
