Euthanasia in Mental Suffering—Overview and Discussion of the Arguments of the Roman Catholic Church

: Euthanasia for mental suffering in a nonterminal situation has been decriminalized only in a few countries, including Belgium, under certain conditions. The aim of this article is to provide an overview and an ethical discussion of the arguments of the Roman Catholic Church concerning euthanasia in mental suffering. In the research material, we include documents from the Vatican’s Magisterium, with particular reference to the recent Letter Samaritanus Bonus , and from the Belgian Bishops’ Conference. We structure the many arguments around three values: the inviolability of life, the good care by the professionals and the patients’ experience of meaning. We discuss the arguments and ﬁnd that they are strongly normative and do not enter into discussion with scientiﬁc positions and other worldviews. As a result, the arguments are not convincing for people with a different view, while the underlying values remain very valid. This is why we nuance and reinterpret certain arguments. Based on Pope Francis’ Exhortation Amoris Laetitia , we make a plea to place less emphasis on the norms and rules, and more on the conscience of those involved and on their ethical discernment of the underlying values.


Introduction
Euthanasia has been decriminalized under certain conditions in an increasing number of countries around the globe. It usually concerns patients in a terminal situation due to an incurable somatic disease. Only in a few countries is euthanasia no longer punishable under certain conditions for nonterminal patients with unbearable mental suffering. The latter is highly controversial because these persons are not terminally ill on a somatic level and because the irremediable nature of their mental suffering is almost impossible to establish. Religions, in particular, are overly critical of euthanasia in any situation, and always consider it immoral.
Our objective is to provide an overview and ethical discussion of the arguments of the Roman Catholic Church regarding euthanasia in mental suffering. We limit our focus to the Catholic Church because, compared with other religions and churches, she has developed the arguments the most extensively, and we belong to that church. We conduct this against the background of the Belgian situation because Belgium has a euthanasia law which includes mental suffering, and we live in that country. Despite these limitations, the overview and discussion are also pertinent for people from countries that do not have such legislation or are preparing such legislation, and also for people who belong to a different church or religion. The arguments and ethical reflections can be interesting and enlightening when the issue arises.
We study the documents of the Roman Catholic Church on euthanasia, especially in relation to mental suffering. Primarily, we include the official documents of the Church's Magisterium, in particular the recent Letter Samaritanus Bonus which reiterates and summarizes the arguments (Congregation for the Doctrine of the Faith 2020). Here, we meet the general position on euthanasia for the universal Catholic Church. We also find this position in statements and letters from the Belgian Bishops' Conference. They specifically address the developments of euthanasia for mental suffering in Belgium. To provide an overview of the arguments, we can structure them along three fundamental values regarding euthanasia: the value of inviolability of life, the value of good care by the care professionals and the value of the experience of meaning by the patient (Liégeois 2021, pp. 38-52). Finally, we explore what the innovative approach of Pope Francis in his Apostolic Exhortation Amoris Laetitia might mean for this issue (Francis 2016).
In this study, we confine ourselves to euthanasia for mental suffering. For careful ethical reflection, it is important that we define this concept precisely. It does not concern the psychological suffering that all people experience at some point in their lives. We focus first on persons with a "severe mental illness" (SMI), who, according to the Dutch consensus definition, suffer from a psychiatric disorder which "requires psychiatric treatment", which is "accompanied by serious restrictions in the social and societal functioning" and which "is not transient", thus last "at least several years" (Delespaul and de Consensusgroep EPA 2013, pp. 429-30, own translation). Next, we focus on these persons as far as they experience "a medically futile condition of constant and unbearable physical or mental suffering that can not be alleviated, resulting from a serious and incurable disorder caused by illness or accident", as defined in the Belgian euthanasia law (The Belgian Act on Euthanasia 2003, sect. 3).
We also need to define the concept of euthanasia properly. The Church's teaching defines euthanasia as "an action or an omission which of itself or by intention causes death, in order that all pain may in this way be eliminated" (Congregation for the Doctrine of the Faith 1980, no. I; Congregation for the Doctrine of the Faith 2020, no. V.1). This definition is different from the generally accepted and legal definition of euthanasia in Belgium, which is "intentionally terminating life by someone other than the person concerned, at the latter's request." (The Belgian Act on Euthanasia 2003, sect. 2). For the Church, two elements are essential in euthanasia, namely the act and the intention: the act causes the death, and the intention is to kill. Both elements are impermissible for the Church in any situation. The Magisterium has several arguments in this regard.

Fundamental Value
The main argument of the Church's Magisterium against euthanasia is that human life, and consequently the inviolability of life, is a fundamental value: "Human life is the basis of all goods, and is the necessary source and condition of every human activity and of all society. Most people regard life as something sacred and hold that no one may dispose of it at will, but believers see in life something greater, namely, a gift of God's love, which they are called upon to preserve and make fruitful" (Congregation for the Doctrine of the Faith 1980, no. I). Denying the value of life leads to a "throw-away culture" and a "culture of death" in which human lives are seen as "discarded lives" or "unworthy lives" (Congregation for the Doctrine of the Faith 2020, no. IV; John Paul 1995, no. 64).
The argument from the value of life has great evidential significance: the inviolability of life is the foundation of and condition for all other values. Those values can only be realized if the value of life is protected. This is also the case for the value of autonomy, which is paramount for many in our society: autonomy too can only be implemented if and as long as life itself is protected.
That the inviolability of life is fundamental means that it has its foundation or basis in itself and is not derived from anything else. The foundation of the inviolability of life lies in being human itself, that is, in the fact that persons are human and belong to the human community. All human beings are created in the image and likeness of God (Gn. 1,26). Because of their divine creation and despite their many differences, all human beings are equal in dignity and protection. To let the inviolability depend on the qualities of life would jeopardize the protection of people, especially the most vulnerable groups in society (Meulenbergs and Schotsmans 2005, pp. 127-41). Persons with severe mental illness are not less worthy of protection because they are vulnerable or suffer unbearably and hopelessly. On the contrary, they deserve more protection. Therefore, inviolability is founded in life itself, and not in its qualities. This is also the case in the preamble of the Universal Declaration of Human Rights which states that the "foundation" of human rights lies in "the recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family" (United Nations 1948, Preamble).
It is possible, however, that the fundamental inviolability of life may be ethically interpreted as absolute. Philosophically, absolute means "total and complete" and "existing or measured independently and not in relation to anything else" (Oxford Advanced Learner's Dictionary 2002). Inviolability is then considered to be total in itself, independent of other values. This may lead to inviolability being placed above all other values. However, this is a far-reaching conclusion that needs to be justified. It is not because inviolability is inherent and a prerequisite for the realization of the other values that it can be evaluated independently of them and would a priori take precedence over them. Whether inviolability or one or more other values are prioritized must be justified time and again by evaluating the proportionality of the underlying values in concrete human action as a whole and in its context (Hoose 1987, pp. 69-100;Kaczor 2002, pp. 119-40).

Natural Law and Self-Preservation
A second argument for the inviolability of life is natural law, more specifically the self-preservation of human beings. The Magisterium affirms that "this doctrine is based upon the natural law and upon the written Word of God, is transmitted by the Church's Tradition and taught by the ordinary and universal Magisterium" (John Paul 1995, no. 65; Congregation for the Doctrine of the Faith 2020, no. V.1). However, what exactly the doctrine of the natural law entails, the Church documents do not explain. However, the Magisterium does state that the related suicide has to do with self-preservation: "suicide is also often a refusal of love for self, the denial of a natural instinct to live" (Congregation for the Doctrine of the Faith 1980, no. I).
We can understand the argument from natural law and self-preservation as follows (Gula 1989, pp. 220-49;Hughes 2003, pp. 47-56). God in his creation gave humans the natural inclination to strive for the good. What is good, humans can deduce from the natural order that God has established in creation, thanks to the reason that they have received from God. The natural law is the moral law that human beings can discern with their reason in creation. Well, reason teaches that life is a good and death is an evil, despite the belief in an afterlife. So, people should love their own life and strive to preserve it. Ending life goes against natural law.
The self-preservation argument ties in with the general human experience of wanting to live (Kuitert 1993, pp. 35-40). People experience life as a good, they want to live and fight to stay alive, even in difficult circumstances. Many attempted suicides are a cry for help or to not have to continue living that way. It is possible that people no longer want to live because they really cannot live with suffering that is unbearable and hopeless. However, that is still different from actually not wanting to live anymore and being dead (Van Tongeren 2018, pp. 85-103).
However, there are many philosophical criticisms of the presuppositions of natural law as foundation of self-preservation (Van der Ven 2010, pp. 61-74). A first criticism of self-preservation in natural law is that it is a very rational approach to human action: because people know the good, they must naturally act accordingly. Human sciences show that there are also a large number of psychological and social factors that influence human action. Second, the self-preservation argument contains circular reasoning: there is a duty of self-preservation because life is a good. Thus, it has already been assumed that life is a good, and death is an evil. The observation that most people want to live on cannot lead to the universal statement that all people want this. Persons with severe mental illness who suffer unbearably and hopelessly are a sign of this. Finally, there is a problem with the normative nature of self-preservation in natural law. The determination that people want to preserve life cannot lead to the normative statement that they should go on living and that ending life is impermissible. Between establishing facts that are, and deriving the moral norm that implies an ought, there is a value judgment that cannot find its foundation in these facts.

Gift and Ownership
The Church's Magisterium grounds the previous philosophical arguments in two theological arguments for inviolability. The first argument concerns precisely the divine nature of creation and consequently God's rule. Life is "a gift of God's love, which they are called upon to preserve and make fruitful" (Congregation for the Doctrine of the Faith 1980, no. I). Euthanasia "constitutes a murder gravely contrary to the dignity of the human person and to the respect due to the living God, his Creator" (Catechism 1997(Catechism , no. 2277. Moreover, God is the Lord of life: "God alone has the power over life and death: "It is I who bring both death and life" (Dt 32:39)" (John Paul 1995, no. 66). People do not simply dispose of life, and by ending life, they violate God's rule over life.
This argument plays a vital role and is accepted with great self-evidence in many people's experiences of faith. Life is a gift and a task. They see God as the giver of life and at the same time as the lord or owner of life. However, there is an internal tension in this argument: life is a gift from God, but God remains the owner of the gift (Kuitert 1993, pp. 119-27; Van der Ven 2010, pp. 74-91). This is not usually how people experience a gift. They see themselves as the new owner of the gift and bear responsibility for it, otherwise it was not a real gift. Many persons with severe mental illness who suffer unbearably and hopelessly no longer experience life as a gift.
From the belief in creation, people do not see themselves as the unlimited owners of life but rather as the stewards who have been given full responsibility for the care of life. People see life as a gift, for which they take care of themselves throughout the course of life, up to and including death. Constantly intervening through human and medical care, people themselves bear the responsibility for their lives. In the argument of the Magisterium, God's ownership of life takes precedence: He is the Lord of life, remains responsible for life, and decides on life. For many people, however, life as a gift and human responsibility for that life go hand in hand and both are essential.

Fifth Commandment
A final theological argument for inviolability refers to divine law. Killing is a grave violation of the law of God, specifically of the fifth commandment: "Thou shalt not kill" (Ex. 20:13). Consequently, the Church's Magisterium affirms that "euthanasia is a grave violation of the Law of God, since it is the deliberate and morally unacceptable killing of a human person" (John Paul 1995, no. 65; Pontifical Academy for Life 2000, no 5; Congregation for the Doctrine of the Faith 2020, no. V.1). Euthanasia, according to the Magisterium, is a violation of this commandment both according to act and intention: "euthanasia's terms of reference, therefore, are to be found in the intention of the will and in the methods used" (Congregation for the Doctrine of the Faith 1980, no. II; Congregation for the Doctrine of the Faith 2020, no. V.1; Pontifical Council [2016] 2017, no. 168). Yet the act in itself prevails over the intention: "euthanasia, therefore, is a homicidal act, which no end can justify" (Pontifical Council [2016 and "the error of judgment into which one can fall in good faith does not change the nature of this murderous act, which must always be forbidden and excluded" (Catechism 1997(Catechism , no. 2277).
The question is whether "thou shall not kill" is a good translation of the original text. In many recent translations, "thou shall not murder" is chosen because exegetes and translators consider it a more correct translation (Van der Ven 2010, pp. 76-77). This difference in translation is of significant importance. After all, a distinction is made between killing and murdering. "Killing" only describes the act as ending life. "Murdering" adds something to this act, namely that this killing is unjustifiable. Whether killing is justified or not then depends not only on the life-terminating act itself but also on other factors, such as the intention and the circumstances.
This way of moral reasoning is used by the Magisterium on other issues that also involve killing. This is known in Catholic moral theology as the principle of "sources of morality" (Gula 1989, pp. 265-79;Selling 2016, pp. 23-27). To assess the moral character of human action as a whole, three sources are taken into account: the intention, the act in itself and the circumstances. Acting in its entirety is justified if the intention is directed toward the good, and the act in itself is appropriate or proportional to express or realize that good, and this takes into account the circumstances. The Magisterium applies these three sources of morality to self-defense and just war. Self-defense is killing but not murder under certain conditions (Catechism 1997(Catechism , no. 2263. Killing in self-defense is justified if the intention is not to kill the other person but to save one's own life, and if the circumstances are such that there are no other possibilities of saving one's own life than by killing the other person. In the doctrine of just war, a soldier may kill an enemy soldier if it is not his intention to kill but if killing in those circumstances is the only means of avoiding a mortal danger to others (Catechism 1997(Catechism , no. 2309. Hence, an enemy soldier may not be killed if he is harmless. It is curious that the Magisterium applies the three sources of morality in self-defense and just war, but in euthanasia it prioritizes the act in itself as the decisive source and subordinates the intention and circumstances to the act.

Deontological Duty
A second set of arguments from the Church's Magisterium no longer refers to life per se, but to the value of good care, and thus to care professionals. A first argument for this value concerns the deontology or professional duties. Care professionals have an ethical duty to "always being at the service of life and assisting it to the end" (Pontifical Council [2016. Euthanasia is seen as irreconcilable with good care. The Magisterium points out that "allowing euthanasia would mean a profound and negative change in the vocation of the physician and of medicine. Physicians have the mission to care for and cure people, to promote their lives and not to end their lives. In this way, the relationship of trust between the patient on the one hand and the family and the carers on the other hand, would be severely compromised" (Belgian Bishops' Conference 1994, no. 7, own translation).
It is argued that euthanasia compromises the trusting relationship between care professionals, patient and family. The question is whether this argument takes sufficient account of developments in deontology and ethics. An essential progress is that good care is no longer determined by care professionals and physicians alone, but by the dialogue and the search for consensus between three partners in care: patients, their families and next of kin, and the care professionals and physicians (Liégeois 2021). A legal condition for this is that physicians and care professionals may not intervene without the patient's consent. In the euthanasia law, the patient's "voluntary" and "well-considered" request is an essential condition (The Belgian Act on Euthanasia 2003, sect. 3, par. 1). The autonomous request of the willing patient is the cornerstone of the euthanasia law. Patients' fears that physicians would execute euthanasia without their explicit request are therefore unfounded.
In addition, physicians and care professionals cannot be compelled to perform actions that they deem medically futile or that are contrary to their judgment of conscience. Freedom of conscience is a special provision in the Euthanasia Act: "No physician may be compelled to perform euthanasia. No other person may be compelled to assist in performing euthanasia" (The Belgian Act on Euthanasia 2003, sect. 14). To the extent that it is in accordance with their conscience, physicians and care professionals may consider euthanasia to be a final form of care only if another condition of the Euthanasia Act is also met. This condition states that the physician and the patient must jointly come to the conclusion that there is "no reasonable alternative" to dealing with the unbearable and hopeless suffering than to perform euthanasia (The Belgian Act on Euthanasia 2003, sect. 3, par. 2). As long as the various partners in care engage in honest dialogue and seek consensus, good care and the relationship of trust need not be compromised.

Palliative Care
A second ethical argument concerns palliative care. According to the Church's Magisterium, this offers an alternative to euthanasia. Persons ask for euthanasia because of unbearable and hopeless suffering. However, this suffering can be relieved by palliative care without wanting to end life. There is a substantial difference between pain management and euthanasia: "This difference lies in the intention, the spirit and the mentality behind the action. In the case of pain management, the aim is to take away the pain of someone who is going to die. Euthanasia involves the deliberate termination of life. Caring becomes killing" (Belgian Bishops' Conference 2002, own translation). We remark that in this document, in contrast to the previous cited documents, the intention prevails over the act in itself. Furthermore, the Magisterium expects much from palliative care. "We expect a lot from the further development and expansion of palliative care. This will give us the opportunity to ensure that our loved ones can depart from us in a physically bearable and humane way, instead of having to kill them or have them killed because they can no longer bear it or we can no longer see it" (Belgian Bishops' Conference 2002, own translation). This should also offer an alternative for persons with severe mental illness: "this requires a specific palliative care offer for patients with therapy-resistant mental illnesses." (Belgian Bishops' Conference 2017, own translation).
In palliative care, professionals pay attention to the physical, psychological, social and spiritual aspects of patients' suffering and seek to maximize patients' comfort (European Association of Palliative Care 2009). They refrain from life-prolonging treatments that are no longer effective or useful and administer pain and symptom relief to alleviate suffering. If this is not sufficient, they may lower the patient's consciousness through palliative sedation to adequately control symptoms. Even though these interventions can have a life-shortening effect, they are distinguishable from euthanasia because they do not intentionally end patients' lives, although this distinction can be very blurred in certain situations.
However, it is difficult to present palliative care as an alternative to euthanasia for mental suffering. In Belgium, euthanasia is increasingly being integrated into palliative care where guidance towards euthanasia is one of the options within the offer of palliative care professionals (Vanden Berghe et al. 2013). Moreover, it is possible that patients refuse palliative care, however meaningful, and opt unabatedly for the end of life without further burden of care.
If we focus on euthanasia for mental suffering, another problem occurs. Palliative care was developed for the unbearable and hopeless somatic suffering of patients in a terminal situation, and this is not easily applicable to mental suffering in a nonterminal situation. In these patients, no life-extending treatments need to be instituted, and therefore their omission cannot shorten life. The administration of pain-and symptom-controlling drugs is already carried out in an appropriate manner with psychopharmaceuticals in ordinary psychiatric treatment. Palliative sedation, whereby the patient is rendered unconscious to control psychological suffering, is not a dignified option in patients who are physically able to live a long time.
However, the palliative philosophy can be beneficial in another way. No longer emphasizing therapeutic goals and providing comfort care, aiming at the highest possible quality of life and including spiritual care, do represent meaningful options in the care of persons with severe mental illness who suffer unbearably and hopelessly. Such an approach has been developed in Belgium as an innovative care model under the name of "Oyster care" (Decorte et al. 2020). The shell can close and protect the oyster from harmful behavior, but it can also open and provide more freedom in daily life. There are many possibilities and opportunities for accompanying patients in oyster care, but unfortunately, this does not provide an adequate alternative for all patients requesting euthanasia for mental suffering.

Relative Autonomy
A third set of arguments can be grouped together under the value of experience of meaning, and thus refers to patients. We use "experience of meaning" rather than "meaningmaking" because we believe that people do not simply give meaning to their lives but rather discover or find meaning that they can make their own. The experience of meaning includes both finding and giving meaning. It also places less emphasis on the cognitive nature of meaning and more on the emotional and affective aspects of experiencing meaning. The request for euthanasia follows from the individual's experience that meaning can no longer be found and given to life and suffering, and the consequent decision that life should be ended.
An important and fundamental argument of the Church's Magisterium is the relativization of autonomy. "The alleged right to self-determination starts from an abstract idea of human beings as isolated beings who can make decisions in that capacity. However, human beings are always connected to their fellow humans. ( . . . ) It is precisely this undeniable connectedness makes them an inalienable value to others. The autonomy of beings is therefore not limitless: it is limited by the mutual connectedness" (Belgian Bishops' Conference 1994, no. 4, own translation). Moreover, the Magisterium argues that the right of self-determination is self-defeating in euthanasia. "The so-called principle of autonomy which allows people to take the concept of individual freedom to extremes, pushing it beyond its rational limits, certainly cannot justify the suppression of one's own life or that of another person. Indeed the first premise of personal autonomy is being alive and calls for the responsibility of the person who is free to do good according to the truth. ( . . . ) In brief, to suppress life means to destroy the roots of the human person's freedom and autonomy" (Pontifical Academy for Life 2000, no. 5).
The relativization of human autonomy belongs to the core of the Christian vision of the human person (Liégeois 2017, pp. 410-13). Persons are not simply autonomous individuals but relational beings. They live in connectedness with others, their environment and God, and therefore take responsibility towards them. Relational connectedness is at the core of the Christian faith: as a Trinity, God is a relational being, establishes through creation a relational connection with human beings, and enters into a lasting covenant with them (Catechism 1997, no. 232-67). The relativization of autonomy is essential in Christianity. Philosophically, too, the autonomous will of euthanasia leads to the paradox that the performance of euthanasia abrogates the autonomous will (Van Tongeren 2018, pp. 85-103).
Nevertheless, we want to put the importance of relational connectedness into perspective in turn. The connectedness between human beings should not cancel out their individuality. On the contrary, connectedness is only possible because persons are also individuals. Connectedness and individuality presuppose and balance each other. The essence of being human is not so much connectedness or individuality but the tension between individuality and connectedness (Liégeois 2017, pp. 413-18). Human persons can only fully become individuals in relationship with others and can only enter into relationship from their individuality. Connectedness implies that persons bear responsibility for each other, but responsibility for the other must not therefore override one's own responsibility. This also applies to the request for euthanasia of patients with severe mental illness. It is essential that they take into account their relational connectedness and responsibility, but this should not override the individual's wish and personal responsibility. Finally, the autonomous wish of the willing patient is essential in euthanasia so that no one else decides on the performance of euthanasia except the person concerned, albeit in consultation with the physician.

Meanings of the Request
The next related argument is the significance of the patient's decisions or the request for euthanasia. According to the Church's Magisterium, it is not simply a wish to end one's life. "The pleas of gravely ill people who sometimes ask for death are not to be understood as implying a true desire for euthanasia; in fact, it is almost always a case of an anguished plea for help and love" (Congregation for the Doctrine of the Faith 1980, no. II). We can understand this as follows. "Often this question must be interpreted as a protest against the pain, the fear, the loneliness; perhaps it is even a protest against the living conditions in the hospital, sometimes against the feeling of rejection by family or friends. The request to die often only conveys the fear that the physicians want to keep him or her alive at all costs" (Belgian Bishops' Conference 1994, no. 8, own translation). Finally, the request for euthanasia is the expression of the will to control death because "we are tempted to regard death as a technical problem that we must solve" (Belgian Bishops' Conference 1994, no. 1, own translation).
Indeed, there may be many hidden meanings beneath the request for euthanasia (Vandenberghe 2017, pp. 155-60). The request is not unambiguous but arises from a multitude of motives. Patients formulate some motives explicitly, such as the unbearableness and hopelessness of suffering. However, there are also hidden motives that patients do not express, or that are difficult to express, such as feelings of guilt or the fear of being a burden to others. There may also be unconscious motives of which patients are unaware. It is therefore essential that care professionals and physicians clarify the motives and underlying meanings. It is an explicit legal requirement that they verify that the patient's request for euthanasia is truly "voluntary" and "well-considered", "repeated" and "durable" and "not the result of any external pressure" (The Belgian Act on Euthanasia 2003, sect. 2, par. 1-2). Moreover, an important due diligence requirement is that care professionals and physicians are fully aware of their own hidden motives and possible countertransference that may play a role in them if they want to comply with the euthanasia request (Verhofstadt et al. 2019, pp. 151-53).

Meaning of Suffering
A final argument is of a strongly theological nature and concerns the meaning of suffering. By choosing euthanasia, people flee the religious meaning of suffering and death, as stated by to the Church's Magisterium. "According to Christian teaching, however, suffering, especially suffering during the last moments of life, has a special place in God's saving plan; it is in fact a sharing in Christ's passion and a union with the redeeming sacrifice which He offered in obedience to the Father's will" (Congregation for the Doctrine of the Faith 1980, no. III). Suffering has a religious sense "if it is experienced for love and with love through sharing, by God's gracious gift and one's own personal and free choice, in the suffering of Christ Crucified. In this way, the person who lives his suffering in the Lord grows more fully conformed to him (cf. Phil 3:10; 1 Pet 2:21) and more closely associated with his redemptive work on behalf of the Church and humanity" (John Paul 1995, no. 67). This is a challenging argument, but it only has meaning for those who actually experience this religious experience of meaning. It presupposes a specific experience of faith that few perceive as meaningful in today's Western society (Kuitert 1993, pp. 134-39). Such a religious experience is strongly characterized by an undergoing of suffering, and this is best balanced in the field of tension between resisting and accepting the suffering. Resistance and surrender are two important poles of religious experience (Gesché 1993, pp. 45-99). Enduring unbearable and hopeless suffering in order to make a religious experience possible can tend toward a kind of dolorism: a glorification of suffering for the sake of its deeper meaning. This cannot be the purpose because more balanced forms of religious experience of suffering are also possible.

Preliminary Findings
We so far distinguished three values to which the Church's Magisterium appeals in its position on euthanasia. In each case, we have presented the arguments for these values and made ethical reflections on them. We made critical comments and qualified certain arguments.
Moreover, we would like to note that the arguments are very inner-church oriented. The argumentation consists mainly of referring to past Church documents. A discussion with the medical, psychiatric and human sciences, as well as other philosophical and ethical beliefs and worldviews, is rarely held. As a result, many arguments fail to convince people who hold different views. The Church's discourse would gain strength if it were to enter into dialogue and discussion with other viewpoints.
Even though the arguments are often unconvincing, this does not mean that the values underpinned by these arguments are vain. The strength of the values is much more fundamental than their expression in the arguments. The inviolability of life, the good care by care professionals and the patient's experience of meaning remain essential in a Catholic position on euthanasia and in the moral conviction of many other people, even if certain arguments need to be nuanced. Therefore, it is and remains important for the Magisterium to emphasize these values, especially in a social climate in which these values are less apparent.
If we can say that the arguments are not so convincing, but the values are, then the interesting question arises as to the place of these values in a Catholic position on euthanasia. Throughout history, the Magisterium has often demonstrated a form of rigorism. The Church concretized her values into precise norms and rules. She showed strictness and rigidity in holding out and imposing these norms and rules. The norms took on a doctrinal and absolute character that tolerated no contradiction or exception. The answers were already given before a question was asked. This is not a fruitful ethics that responds to people's sense of responsibility. Ethical reflection is even unnecessary because the answer is already predetermined.

Pastoral Mercy
With Pope Francis, we see an innovative approach making its reappearance in the Catholic Church. It is not the norms that are central but the persons. He approaches persons with pastoral mercy. We find this most strongly so far in Amoris Laetitia, the postsynodal Apostolic Exhortation on love in the family (Francis 2016). This document is, of course, about marriage and family and not euthanasia. The question is what this vision of mercy in relation to moral issues in the family might mean for an ethical approach to euthanasia. When Francis discusses so-called "irregular situations" in the family, he makes room for the "law of gradualness," for "integrating weakness" and "mitigating factors" for "pastoral discernment" and "pastoral mercy" (Francis 2016, no. 291-312). These concepts, of course, must not be taken out of context and must be read from the totality of the text of the exhortation and in continuity with Church teaching. In this sense, Francis does not modify Church doctrine. Nor does he do so regarding euthanasia. He does speak of a "law of gradualness" in the application of the Church's norms but not of a "gradualness of law" or of the Church's norms themselves (Francis 2016, no. 295).
He does change the attitude of the Church's Magisterium toward persons who live in so-called "irregular situations", that is, situations that do not conform to the teachings of the Church. Such a situation also arises when patients with severe mental illness request euthanasia for unbearable and hopeless mental suffering, and when physicians and care professionals are willing to proceed with the performing of euthanasia.

Mercy and Discernment
"The way of the Church is" according to Francis "not to condemn anyone for ever; it is to pour out the balm of God's mercy on all those who ask for it with a sincere heart" (Francis 2016, no. 296). For the sake of mercy, Francis, in accordance with the Catechism of the Catholic Church, takes into account "mitigating factors": "imputability and responsibility for an action can be diminished or even nullified by ignorance, inadvertence, duress, fear, habit, inordinate attachments, and other psychological or social factors" (Francis 2016, no. 302;Catechism 1997Catechism , no. 1735. However, circumstances can also play a role, such as "affective immaturity, force of acquired habit, conditions of anxiety or other psychological or social factors that lessen or even extenuate moral culpability." (Francis 2016, no. 302;Catechism 1997Catechism , no. 2352. Reduced culpability is not the case with patients who ask for euthanasia because, according to the law, their request must be voluntary and considered. However, the situation of unbearable and hopeless suffering can certainly be considered as mitigating circumstances. In pastoral accompaniment, it is necessary "to avoid judgments which do not take into account the complexity of various situations and to be attentive, by necessity, to how people experience distress because of their condition" (Francis 2016, no. 296). This is precisely why pastoral discernment is crucial for Francis: "Under certain circumstances people find it very difficult to act differently. Therefore, while upholding a general rule, it is necessary to recognize that responsibility with respect to certain actions or decisions is not the same in all cases. Pastoral discernment, while taking into account a person's properly formed conscience, must take responsibility for these situations. Even the consequences of actions taken are not necessarily the same in all cases" (Francis 2016, no. 302).
According to Francis, judgment is formed by the conscience of the persons involved in a process of pastoral discernment. This is not new in the ecclesial tradition but had been relegated to the background in the Church's Magisterium. It is to Francis' major credit when he refocuses the role of conscience and discernment.
This discernment does not change the Church's norms, but it does change the way people can deal with these norms from their conscience. In the pastoral discernment of a concrete situation, conscience can "recognize with sincerity and honesty what for now is the most generous response which can be given to God and come to see with a certain moral security that it is what God himself is asking amid the concrete complexity of one's limits, while yet not fully the objective ideal" (Francis 2016, no. 303). Thus, conscience, after sufficient discernment, can come to an honest and ethically sound answer, even if it does not reach the ideal held out in Church's norms.
Persons with severe mental illness who request euthanasia because their mental suffering is unbearable and hopeless, and the physicians and care professionals who may be willing to accede to that request, are in a comparable situation. They too may arrive at a personal decision of conscience in a process of discernment, in which, because of the imperfection of circumstances, they cannot realize the ideal or highest good, but seek a lesser good, or want to avoid a greater evil (Burggraeve 2016, pp. 105-39;Liégeois 2021, pp. 93-95).

General Principles and Particular Situations
Francis' approach ultimately has to do with his vision for dealing with the Church's norms. This vision, which now comes across as innovative, actually belongs to the core of tradition of Catholic moral theology. Francis refers to Thomas Aquinas' distinction in the Summa Theologica between general principles and private situations: "I earnestly ask that we always recall a teaching of Saint Thomas Aquinas and learn to incorporate it in our pastoral discernment: "Although there is necessity in the general principles, the more we descend to matters of detail, the more frequently we encounter defects . . . In matters of action, truth or practical rectitude is not the same for all, as to matters of detail, but only as to the general principles; and where there is the same rectitude in matters of detail, it is not equally known to all . . . The principle will be found to fail, according as we descend further into detail"" (Francis 2016, no. 304;Aquinas n.d., Summa Theologica I-II, q. 94, art. 4).
To reinforce this view, Francis refers not only to an authority of the theological tradition but also to a contemporary authority: the International Theological Commission. "Along these same lines, the International Theological Commission has noted that 'natural law could not be presented as an already established set of rules that impose themselves a priori on the moral subject; rather, it is a source of objective inspiration for the deeply personal process of making decisions'" (Francis 2016, no. 305;International Theological Commission 2009, no. 59).
It is clear that Francis' view is a relativization of the rigor with which the Church's Magisterium has preached and enforced norms without exceptions. Even though Francis limits his exhortation to irregular situations in the family, we can ask what this approach might mean for demanding situations related to the question of euthanasia. In any case, Thomas Aquinas and the International Theological Commission see their relativization of ecclesial norms in a nonlimited scope. Even if they were not thinking about euthanasia, the question again is whether they would apply this relativization to the issue of euthanasia.

Discernment and Conscience
Nevertheless, we want to make a critical reflection on pastoral mercy. There is a certain tension between holding up the Church's norms with a high ideal that is not always realizable in particular circumstances and mercifully accepting and valuing people when they cannot realize these norms. Holding the ideals high is called "ethics", while accepting that the standards are sometimes too high for people is referred to as "pastoral". This tension can come across as condescending and paternalistic to some people. After all, the Church continues to say that their behavior or situation is ethically wrong but accepts their person with pastoral mercy despite their ethical error.
The individuals involved usually feel themselves that they are ethically pursuing the most humane thing possible in their situation. They experience the acceptance of their decision of conscience as something that follows from the sincerity of their discernment process, and not as a pastoral concession to a choice that is seen as ethically wrong. Nevertheless, pastoral mercy is a positive development because it no longer condemns people as human beings. What is important about pastoral mercy is that it is not condescending and fully recognizes the discernment process of the personal conscience.

Conclusions: Values as Inspiration
We want to build even further on the vision of the International Theological Commission. In a negatively worded way, she states that we must not conceive of the natural law as a set of rules to be applied a priori. On a positive note, she recommends that we see the natural law as a source of inspiration with an objective character for the highly personal decision-making process that is always to some extent a subjective matter. This tension between a more objective source of inspiration and a more subjective decision of conscience is very fruitful for ethical discernment.
Precisely because the decision of conscience is always of a subjective nature, it is good that there is a source of inspiration with a more objective character. People should not simply apply the source of inspiration blindly and a priori, but they can discern in their decision of conscience how to give shape to that source of inspiration in particular circumstances. At the same time, there are limits to the subjectivity of the decision of conscience because it confronts the objectivity of an inspiration.
In the discussion of the Church's position, we found a reliable source of inspiration, especially in the fundamental values. The inviolability of life, the good care by care professionals and the experience of meaning by the patient are particularly challenging and interesting inspirations with an objective character for today's people. These values are often at odds with what is going on in society. From its rich tradition, the Church has a strong message. She can play a significant role in the current ethical discussions.
We do better to present these values as an inspiration, without deriving absolute norms from them. The values are at the level of ethical inspiration. It is up to the persons themselves to make ethical distinctions. The values are then an important indication of what is good in the choice they make. However, it is the persons themselves who make the decision from their conscience and are responsible for it. This too is part of the Catholic tradition.