While the majority of human deaths are “natural” , being the result of aging, injury or disease, the choice of “voluntary” death — suicide, assisted suicide and euthanasia (SASE) — has been a human response to the problems of life since the beginning of recorded history. In the West, social acceptance of these actions has varied over time. Two periods of transition in popular attitudes toward voluntary death can be identified. The first shift – from approval to disapproval — may be defined by the transition from the pagan cultures of antiquity toward a new Judaeo-Christian civilization built on Greco-Roman foundations. The second shift — which we are currently living through — is characterized by the emergence of cultural attitudes more tolerant of voluntary death driven by a gradual loss of the sense of the transcendence of human existence.
In this article, I point out some of the historical factors which surrounded and to a certain degree caused these shifts in attitude. These factors include conflicting views of the nature of human life; how diseases were understood and medicine was practiced; and how scientific advances might have influenced the transitions.
Voluntary death in pagan antiquity
For the Greek and Roman societies that preceded the appearance of Christianity, a “good death” could be either natural or voluntary. The practice of voluntary death was widespread, and depending upon the circumstances was considered to be a reasonable act. To relieve the pain or distress of an incurable illness, to avoid a humiliation or indignity, to end an unhappy or tiresome life or to express a sense of triumph over Fate by ending one’s life voluntarily in old age were felt to be justifiable or even honorable reasons to end one’s own life. In some cases, the governing regime of a Greek or Roman city would reserve doses of the appropriate poisons to give to those to whom voluntary death was permitted. In certain areas of the Greco-Roman world, suicide was a privilege reserved for the social elites and not permitted to soldiers, slaves or criminals. When a person committed suicide without apparent justification, their corpses were sometimes mutilated and buried shamefully in unmarked graves.
|The first transition from approval to disapproval of voluntary death seems to have been initiated by the heroic attitude of service of ordinary people toward their suffering peers, actions which clashed with the prevailing standards of socially acceptable behavior.|
Pagan antiquity was characterized by a pessimistic attitude toward human existence, and individual human life lacked special significance or value. Within this context, there arose philosophical “schools” around great teachers, wise men whose advice was sought as a guide to ethical living and release from despair. The various philosophical schools shaping Greco-Roman culture reflected an eclectic and tolerant attitude toward voluntary death. In general terms, materialist schools, including the Stoics and Epicureans, adopted permissive or supportive attitudes toward SASE. Their view of the human individual included no sense of personal immortality. Death was annihilation: a natural, personal dissolution. With death, individuality and personality ceased to exist. In contrast, Greek philosophical schools admitting the existence of transcendent, spiritual realities in the Cosmos tended to limit or caution against voluntary death. These groups — including the Platonic, Aristotelian and Pythagorean schools — acknowledged the possibility of a personal, individual existence after death.
From within the Pythagorean school, a unique group of philosopher-physicians emerged who challenged the attitudes toward SASE that prevailed at the time. Best known among them was Hippocrates. These physicians distinguished themselves for several reasons.
First, they attempted to work according to a set of well-defined professional standards, entered into by means of a solemn oath to the gods. Often the healers of antiquity were merchants of tonics and cure-alls, “root cutters” or “sorcerers”. They often traveled from place to place pushing their particular brand of treatment for profit. In other contexts, healers were also drawn from among slaves and soldiers, offering treatment for injuries incurred during their labors. The physicians of the Pythagorean tradition on the other hand were often attached to the temples of Asclepius, god of health, whose aid they sought and with whom they “collaborated”. The bond of their collaboration took the form of an oath or promise taken after an apprenticeship. The oath was meant to define (or outline) the proper standards of behavior expected of the physicians of this school. Known today as the Hippocratic Oath, it included the first known prohibition of physician assisted suicide in Western history. It is worth noting that the prohibition of assisted suicide found in the Hippocratic Oath ran in direct opposition to the permissive attitudes toward SASE of that historical period.
Second, they tended to reject the widespread, popular notion of disease as divine punishment, and sought natural rather than supernatural explanations for them. They developed a rational process of clinical problem solving — patient interview and examination, diagnosis, prognosis and therapy — which continues to be the standard medical practice today.
Third, they viewed human existence as bound up with the whole of nature, in an orderly not chaotic or random way. Recognizing a tension and balance of opposing qualities throughout the Cosmos, they developed an understanding of human physiology made up of four humors (blood, phlegm, yellow bile, and black bile) located in four organs (heart, brain, gall bladder and spleen). These elements were correlated with four basic human personality traits or temperaments (sanguine (cheerful), phlegmatic (sluggish), choleric (irritable), melancholic (sad)). Similar patterns were correlated to natural phenomena, including the four elements of the cosmos (fire, earth, water, air) and the four seasons of the year (summer, autumn, winter, spring), the four natural sensations (hot, cold, dry, wet) and in the four geographical points (east, north, south, west). Diseases were the result of disequilibrium between man’s humors and nature’s elements. The task of medicine was to restore the equilibrium. For over 1500 years — through the Middle Ages and well into the 18th century — medical practice was based on these principles.
The rise of compassion
With the progressive collapse of the Roman political order and the gradual emergence of a Christian culture, popular acceptance of voluntary death declined. According to some scholars (for example, Rodney Stark), the clear contrast between pagan and Christian approaches toward the sick was an important factor contributing to this change in attitude toward SASE. In the Greco-Roman world, basic forms of welfare and philanthropy were based on principles of reciprocity and self interest. There was no public duty toward the sick, and sympathy for strangers was considered irrational.
Below you will read the eye-witness accounts of two plagues: one by the historian Thucydides describing what he saw during the plague of Athens in 431 BC; the other by Pontius the Deacon and Cyprian, bishop of Carthage describing the plague that struck that city in 251 AD. Thucydides captures the despair and lawlessness which overcame the Athenians when confronting a devastating epidemic:
People were afraid to visit one another, and so they died with no one to look after them, and many houses were emptied because there was no one to provide care. … The doctors were incapable of treating the disease because of their ignorance of the right methods…. Equally useless were the prayers made in the temples, consultation of the oracles, and so forth. In the end people were so overcome by their sufferings that they paid no further attention to such things. The great lawlessness that grew everywhere in the city began with this disease, for as the rich suddenly died and the poor took over their estates, people saw before their eyes such quick reversals that they dared to do freely things they would have hidden before, things they would never have admitted they did for pleasure. And so, because they thought their lives and their property were equally ephemeral, they justified seeking quick satisfaction in easy pleasures. As for doing what had been considered noble, no one was eager to take any further pains, because they thought it uncertain whether they should die or not before they achieved it. But the pleasure of the moment and whatever contributed to that were set up as standards of nobility and usefulness. No one was held back in awe either by fear of the gods or by the laws of men: not by the gods because men concluded that it was the same whether they worshipped or not, seeing that they all perished alike; and not by the laws, because no one expected to live till he was tried and punished for his crimes. But they thought that a far greater sentence hung over their heads now, and that before this fell they had a reason to get some pleasure in life. Such was the misery that weighed on the Athenians.
Confront this account with letters written by the Christians of Carthage. They had just (barely) survived a persecution by the Emperor Decius and now faced a devastating epidemic similar in every respect to the plague of Athens. Pontius describes the devastating scene and Cyprian describes the Christian response.
There broke out a dreadful plague, and excessive destruction of a hateful disease invaded every house in succession of the trembling populace, carrying off day by day with abrupt attack numberless people, every one from his own house. All were shuddering, fleeing, shunning the contagion, impiously exposing their own friends, as if with the exclusion of the person who was sure to die of the plague, one could exclude death itself also. There lay about the meanwhile, over the whole city, no longer bodies, but the carcasses of many, and, by the contemplation of a lot which in their turn would be theirs, demanded the pity of the passers-by for themselves.
From Cyprian of Carthage we read:
This trial — that now the bowels, relaxed into a constant flux, discharge the bodily strength; that a fire originated in the marrow ferments into wounds of the fauces; that the intestines are shaken with a continual vomiting; that the eyes are on fire with the injected blood; that in some cases the feet or some parts of the limbs are taken off by the contagion of diseased putrefaction; that from the weakness arising by the maiming and loss of the body, either the gait is enfeebled, or the hearing is obstructed, or the sight darkened — is profitable as a proof of faith. What grandeur of spirit it is to struggle with all the powers of an unshaken mind against so many onsets of devastation and death! What sublimity, to stand erect amid the desolation of the human race, and not to lie prostrate with those who have no hope in God; but rather to rejoice, and to embrace the benefit of the occasion; that in thus bravely showing forth our faith, and by suffering endured, going forward to Christ by the narrow way that Christ trod, we may receive the reward of His life and faith according to His own judgment!
Clearly, this way of looking at the brutal world in which they lived was different than that of the pagans: the Christians had discovered new values that influenced the way they faced the dilemma of human suffering. There are well documented accounts of Christians during this plague caring for and not abandoning the dying, including those who had lapsed under the recent persecution and those who had been their persecutors.
And so this first transition from approval to disapproval of voluntary death — a change that might accurately be characterized as revolutionary rather than evolutionary — seems to have been initiated by the heroic attitude of service of ordinary people toward their suffering peers, actions which clashed with the prevailing standards of socially acceptable behavior. In these first steps of transition, we can glean a merging of those rich elements of Greco-Roman culture compatible with Christian anthropology, an anthropology that was first lived, and then explained.
The first systematic argument against suicide in Christian thought appears to occur in the 4th century, when Augustine of Hippo argued in The City of God against the justification of suicide by Christian women who had been violated by barbarian soldiers. He made his case based on both logical argumentation and reference to Scripture. Elsewhere, he also admonished against assisted suicide, in the following terms:
…it is never licit to kill another: even if he should wish it, indeed if he request it because, hanging between life and death, he begs for help in freeing the soul struggling against the bonds of the body and longing to be released; nor is it licit even when a sick person is no longer able to live.
Over 1500 years — from the 4th to the 19th centuries — notions of reverence for individual human life, of the dignity of self-sacrifice on behalf of others, and of the redemptive value of suffering took root in the popular imagination. In time pagan tolerance toward voluntary death came to be considered profoundly objectionable. This objection was expressed throughout society in popular customs, literary works, legal systems and medical practices which formally and enthusiastically prohibited SASE.
Over the same period of time, while the intellectual foundations of a Christian culture were being laid, devastating epidemics swept through Europe and other parts of the world over and over again. Despite profound ignorance of their causes, despite a lack of effective treatment to cure or prevent them, despite terrible suffering, there was universal opposition toward suicide, assisted suicide or mercy killing during the historical period in which Judeo-Christian attitudes prevailed among the general population. During this time, the care of the sick by Christians grew in efficiency and organization, the direct precursors of today’s hospitals.
Scepticism and the rationalization of voluntary death
Weakening of the collective social disapproval of SASE began with a decline in the moral authority of the Roman Catholic Church. This decline culminated in the protestant reformation of the 16th century, and eventually led to the institutionalization of “secular” opposition toward the Catholic Church. As God receded from the human orbit, the social customs, legal principles, academic and political institutions, and economic practices that reflected the principle of reverence for individual human life slowly weakened. Eventually intellectuals, scientists and clergy would begin to seek justifications for SASE.
The first break probably occurred among English intellectuals who began to debate a variety of rationalizations of suicide and voluntary death in the 18th and 19th centuries, and with particular enthusiasm following the French Revolution. The debates were motivated in part by an apparent epidemic of suicides throughout England in the 18th century, a phenomenon which led to suicide being designated “the English malady”. These debates were limited to elite intellectual circles, with very little sympathy gained among the general population. By the mid 19th century, several additional factors contributed to growing interest in and impetus for justifications of SASE.
First, social and political upheavals (the Reformation, the Thirty Years War, the Enlightenment, the Reign of Terror, the Napoleonic Wars) led to a generalized pessimism and moral relativism throughout Europe.
Second, materialist philosophical projects developed in direct opposition to the basic principles of Christian anthropology. Among these projects was the theory of “transmutation” or “evolution” which held that matter possessed the intrinsic capacity to randomly develop all known forms of life over very long stretches of time. By offering evidence for the “natural selection” of traits that conferred survival advantages on animals, Charles Darwin came up with a scientific support for the theory of evolution. His findings were used by others, including his cousin Francis Galton and the philosopher Herbert Spencer, to advocate a social philosophy promoting the improvement of human hereditary traits through selective breeding of humans, birth control and euthanasia in order to create healthier, more intelligent people, to save society’s resources and to lessen human suffering.
Darwin and others reasoned that charitable efforts to treat the sick and support the mentally or physically disabled could adversely affect the human race, leading to a “degeneration” of the human condition by favoring the survival of defectives. Their approach became known as “eugenics” or “the self-direction of human evolution”, a view that found support among intellectual circles in Anglo-Saxon countries first and later — with particularly terrible consequences — in Germany.
Third, developments in science led to a surge in popular confidence in the ability of physicians to uncover the basic causes of human diseases and to treat them effectively. Two early scientific advances are especially relevant to our topic.
The first is the verification of the “germ theory” of Koch and Pasteur. It could now be said that the mysterious diseases that repeatedly killed large fractions of European and other peoples over the centuries were caused by invisible living organisms. Soon after, vaccines proved effective in preventing these diseases, and by the first half of the 20th century, antibiotics began to cure many of those infected.
A second event affecting the SASE debates was the discovery of analgesic and anesthetic chemicals. In preceding centuries, physicians had little to offer patients in pain, but toward the middle of the 19th century, chemicals that could reversibly alter human consciousness and pain perception — including chloroform, ether and morphine – could be given to the sick and dying to ease their distress. Some intellectuals argued that these chemicals should be used to cause the deaths of persons who were suffering excessively. However, no physicians are known to have publicly recommended this practice for their patients until the “euthanasia movement” began, first in Great Britain and soon after — by the early 20th century — in the United States.
Historical evidence suggests that the euthanasia movement of the late 19th and early 20th century and the contemporary right-to-die movement are campaigns organized by social elites — including intellectuals, Protestant and Unitarian clergy and wealthy agnostics – to overcome deep-seated popular opposition to voluntary death in its various forms.
In summary, over the course of Western history, changes in social acceptance of SASE have been driven primarily by re-examinations of the dominant cultural views regarding the nature and meaning of human existence in a particular historical period, and to a lesser extent by developments in medical care. One could argue that the first shift — from approval to disapproval of voluntary death — was driven by a “grass roots” movement, where ordinary people, inspired by a new understanding of who they were, acted with extraordinary heroism and encouraged others to do the same. The second shift on the other hand presents itself as a “top-down” imposition of ideology on a popular culture which struggles to retain its Judaeo-Christian identity. The first shift involved the assimilation of Greco-Roman values of rationality into a lifestyle characterized by the radical gift of self. The second involves the withdrawal of man into himself and his alienation from God, the source of rationality.
Jose A. Bufill, MD, lives in South Bend, Indiana where he works as a
cancer specialist. His articles on bioethics have appeared in the
opinion pages of major US newspapers. Some of them may be read at www.brasstack.blogspot.com
 Thucydides. The Peloponnesian Wars, numbers 50-54.
 From Pontius, The Life and Passion of Cyprian, the full text of which may be found at http://www.users.drew.edu/ddoughty/Christianorigins/persecutions/cyprian.html
 The Treatises of Cyprian; Volume V: Fathers of the Third Century, page
472, number 14. In: Roberts A, Donaldson J (eds). The Ante-Nicene
Fathers: Translations of the Fathers down to AD 325, Wm B. Eerdmans
Publishing Company, Grand Rapids, Michigan, 1995.
 Augustine. Epistola 204; 5: Corpus Scriptorum Ecclesiasticorum Latinorum 57, 320. Quoted in Pope John Paul II, Evangelium vitae, 66.