Is Presence Always Complicity? An Analysis of Presence,Its Moral Objects,and Scandal in Proximity to Physician-Assisted Suicide and Euthanasia

Presence When? PAS-E Is a Process, Not Merely a Moment

In the context of the question being addressed here—presence in proximity to PAS-E—it is important to begin with some contextual information about the legal frameworks that make PAS-E possible. Though such legislative frameworks vary, what is common is that the act is made possible through a process of assessment and approval, normally governed by medical professionals.

For example, in Victoria, Australia, Voluntary Assisted Dying (hereafter, VAD) has been legal since 2019 and provides a pathway for eligible individuals to end their lives by means of assisted suicide. In order to access VAD, a person is assessed by two independent medical practitioners. If these agree that the person meets the established criteria, they are eligible to receive a permit for a lethal drug, which is delivered by a centralized pharmacy. ⁴ If and when they choose to use it, they take anti-nausea medication, wait for a period of time, prepare the lethal substance, and consume it. ⁵ In Victoria it has been reported that it can take around one to two hours for the drug to cause the person’s death. ⁶ However, the US states of Oregon and Washington, which have similar regimes, report different median times: five minutes between ingestion and coma, and twenty-five minutes between ingestion and death. Moreover, the range reported in Oregon and Washington is significant, with some who consume the lethal substance taking up to eleven hours to fall into a coma, and in extreme cases over four days to die. ⁷

As this overview shows, there are a number of distinct steps in the process required to access VAD in Victoria—assessment, drug access, individual planning, and ingestion or consumption—and these steps are a consistent feature in jurisdictions with similar regulations. Each of these steps takes place over an unpredictable period of time, and all are integral to PAS-E. Whereas the debate surrounding presence and PAS-E has focused on the moment of ingestion of the lethal substance (or injection, if it is euthanasia in question), such a focus fails to recognize the moral saliency of presence in the context of the discreet moments in time leading up to—and indeed following—ingestion of the lethal substance. This understanding of PAS-E as a process, rather than a specific moment in time, underpins the discussion that follows.

Debate about Presence in the Church

In December 2019, Archbishop Vincenzo Paglia, president of the Pontifical Academy for Life, was asked by the media about pastoral accompaniment of a person pursuing PAS-E. An America Magazine report on this interaction notes that the question arose out of a document of the Swiss National Bishops Conference, which states that any Catholic spiritual caregiver “has the duty to leave the patient’s room during the suicide act.” ⁸ In response to the question, Paglia remarked, “According to us, no one should be abandoned, we are against assisted suicide because we don’t want to do death’s dirty work. To accompany and hold the hand of the dying, I believe, is a great responsibility that every believer must promote. Just as every believer must promote an opposition to the culture of assisted suicide.” Paglia added that a “society that rushes toward a point of view that justifies suicide or a point of view that abandons those who are not good, is a cruel society. That is why I am convinced that no one must ever be abandoned, no matter what situation they are in.” ⁹

Much of the media reporting on Paglia’s remarks gave the impression that his comments unequivocally endorsed priests being present for assisted suicides, and that he himself would hold the hand of a person dying in this way. ¹⁰ This drew swift, oppositional reaction from some in the church who argued that any such presence would amount to complicity with PAS-E, and on that basis would be illicit. Most prominently, Dutch Cardinal William Eijk said that the “priest must not be present when euthanasia or assisted suicide are performed” because this presence “might suggest that the priest is backing the decision or even that euthanasia or assisted suicide are not morally illicit in some circumstances.” ¹¹

It is important to note that the issue of concern here is presence specifically, not other potential or actual complicity in relation to PAS-E. ¹² With this in mind, two initial moral considerations arise in this debate that are relevant to those providing spiritual care (such as priests and pastoral caregivers) and those providing clinical care (such as doctors and nurses). ¹³ The first is whether the morally good commitment to accompanying a person could lead a caregiver to be present in proximity to the PAS-E process. The second is whether presence in and of itself amounts to complicity with PAS-E. It is clear that if the latter holds, then the former is impossible. As indicated earlier, both considerations are relevant across the entire process of PAS-E, not only at the time of lethal ingestion or injection.

With this in mind, the CDF’s 2020 promulgation of Samaritanus Bonus provides the following in the context of guidance for those providing spiritual care to someone who is seeking after PAS-E.:

It is necessary to remain close to a person who may not be in the objective condition to receive the sacraments, for this nearness is an invitation to conversion, especially when euthanasia, requested or accepted, will not take place immediately or imminently. Here it remains possible to accompany the person whose hope may be revived and whose erroneous decision may be modified, thus opening the way to admission to the sacraments.

Nevertheless, those who spiritually assist these persons should avoid any gesture, such as remaining until the euthanasia is performed, that could be interpreted as approval of this action. Such a presence could imply complicity in this act. This principle applies in a particular way, but is not limited to, chaplains in the healthcare systems where euthanasia is practiced, for they must not give scandal by behaving in a manner that makes them complicit in the termination of human life. ¹⁴

Two considerations are important here. First, Samaritanus Bonus differentiates between presence in the lead up to PAS-E, and presence at the time of the act itself (here meaning the ingestion or injection of a lethal substance). It is clear that the CDF sees the moral problem of proximity as more salient at this part of the process. I will return to this point below. Second, though the bulk of this part of this letter is more or less the same across translations, the italicized text in both paragraphs is different. Taking the German for contrast, the first sentence reads, “Therefore, even if a person is not in the objective condition to receive the sacraments, a nearness is necessary, which is always an invitation to conversion.” ¹⁵ This same meaning is carried in the Spanish, Italian, and French versions of the letter. ¹⁶ In these, nearness is given an additional emphasis, as always opening up an invitation to conversion. I will return to this in the final section of the article.

The difference between the English and other translations is also present in the second italicized sentence. Taking the German once more, the wording here is, “Such a presence can only be interpreted as participation.” ¹⁷ Again, the same meaning is carried in the Spanish, Italian, and French versions of Samaritanus Bonus. ¹⁸ Whereas the English warns against presence because it could be interpreted as complicity, other translations suggest that presence can only be interpreted as complicity. ¹⁹

Notwithstanding this difference, the ethical problem that the CDF anticipates in this paragraph is straightforward and is a development of the positions considered above. Here the focus is refined to the problem of scandal, by way of actions on the part of a moral authority which lead others into moral error. ²⁰ For example, a Catholic doctor stays by the bedside of someone receiving euthanasia to encourage their decision. The same person—assuming they are upheld as a moral authority in their hospital—gives staff and other patients the impression that they endorsed this, leading others to support or even choose the same action. This would be a clear-cut case of scandalizing both the person pursuing PAS-E and the others in the community. ²¹ Once again, note that such complicit presence could be enacted at any point throughout the PAS-E process, not only at the time of ingestion or injection.

In the next two sections I analyze and respond to the two ethical issues that are central to this debate. The first is whether the act of being present must always and necessarily be complicit presence in proximity to the PAS-E process. The second is whether presence is always and necessarily an occasion for scandal. Both are significant. On the one hand, if presence as an action is always and necessarily complicit presence, it will always be illicit. On the other hand, even if presence as an action can be considered good in some cases, if it is always and necessarily an occasion for scandal, it is also morally problematic.

Presence as a Moral Action

In evaluating the morality of a given action, the traditional three fonts of Catholic ethics hold together the intention of the acting agent, the moral object of the action chosen, and the circumstances in which it is chosen. For a moral act to be considered ethically good, an acting agent must have a good intention, choose an action that is good or neutral in its object, and commit to it in circumstances in which it is prudent to do so.

Though the overall analysis of an action holds together all three fonts, considering them in their specificity is helpful for precision. To that end, setting aside intention and circumstance for the moment, the first point to be noted here is that “presence” in and of itself does not determine the moral object of a given act. In the case of a chaplain or healthcare professional, presence concerns their physical location at a particular point in time. Noting where and when someone is present, however, is insufficient for moral analysis. This observation has the same structure as a lesson that students of Catholic ethics encounter when they consider whether an act of killing is right or wrong. What they invariably discover is that “killing,” a physical description of an act, cannot be evaluated from the perspective of ethics until one determines the moral object of the action. ²² If the killing has the object of murder, it is wrong, if it has the object of proportionate self-defense, it is licit (even if regrettable).

Returning to presence, this same kind of distinction can be made by noting that there are a variety of proximate ends which can be related to the choice to be present at a particular place and time, and it is only by looking more closely at these that we can arrive at a more accurate judgment about the object of the action concerned.

Consider three examples from different contexts that help to elucidate this point:

Note how these three examples relate to John Paul II’s description of the moral object of actions in Veritatis Splendor:

By the object of a given moral act, then, one cannot mean a process or an event of the merely physical order, to be assessed on the basis of its ability to bring about a given state of affairs in the outside world. Rather, that object is the proximate end of a deliberate decision which determines the act of willing on the part of the acting person. ²⁵

In each of the examples above, we can see how the physical action of “being present” is specified in terms of its moral object, which, as John Paul II argues, can only be discovered by placing “oneself in the perspective of the acting person.” It is in this sense “a freely chosen kind of behaviour” and inasmuch as the object is “in conformity with the order of reason,” it can be declared good. ²⁶ Note how this differs from the claim that presence is one and the same as complicity. Were one to take such a stance universally, one would have to claim that Sr. Prejean and Bryan Cousins were complicit in capital punishment and drug use in their respective situations. It is clear that this argument does not stand, because it does not adequately account for the object of the act in each case.

Appealing to considerations of circumstance and intention further bolsters this analysis in these cases, because in each the object arises from good intentions and is enacted in appropriate circumstances. One can readily see how things would be different if any of these elements were changed. If the parent chooses to provide encouraging presence in an inappropriate circumstance, such as in the team’s private changing room following the game, the good of the action chosen is undermined. If Sr. Prejean’s intention is the seeking of attention, the good is also undermined. And if Bryan Cousins chose to be present with his son because he wanted to help him get drugs, his act would no longer be good and would instead be formal cooperation.

Though taken from different kinds of cases, these reflections indicate how Catholic ethics can assess whether an act of presence in proximity to any aspect of the PAS-E process is morally illicit or not. The cases illustrate three different moral objects that could be associated with the physical act of proximity to PAS-E: presence as encouragement, protest, and the provision of an alternative option. ²⁷ It is clear that the concerns considered above are focused on something like encouragement. If a moral authority is present at any point of a patient’s seeking after PAS-E to offer encouragement for this choice, their action will likely help in the patient’s choosing to commit an intrinsically evil act, thereby becoming complicit in it. Presence with this object, in this circumstance, as an expression of the intent of the moral authority who wishes to encourage the act, is clearly illicit.

That said, it is worthwhile considering whether the same judgment applies to the other two kinds of presence (presence as protest or presence as the offer of an alternative). One can imagine that a chaplain with a well-known conscientious objection to PAS-E who is present at any point in the process could enact a similar object to that of Sr. Prejean at an execution, a peaceful protestor who by their presence is able to protest. One can also imagine the presence of a palliative care physician who has accompanied a patient and is willing to provide palliative care as an alternative to PAS-E functioning in a similar way to Bryan Cousins, by recommending and being ready to enact alternative options that would not be available were they not present. Neither of these is a form of “complicit presence.” In each, the object of the act of presence and the intention of the acting agent are good. In specific circumstances, such as if a person had not yet made a final resolution to enact PAS-E, such presence would be morally good—a position that I defend in the final section.

Determining whether presence is morally good or otherwise requires more than observing where a person is present at a particular place and time—one needs the precision provided through determining the object of the act chosen, the intention of the acting agent, and the circumstances to undertake a full evaluation. The claim that presence is one and the same as complicity does not hold, and I have argued that some kinds of presence in proximity to PAS-E are morally good. Even so, on its own this does not provide a complete response to the concern about presence considered earlier. Indeed, the way the issue is framed in Samaritanus Bonus indicates that the concern is broader than the object of the act concerned and includes its interpretation. This necessitates a consideration of scandal. ²⁸

Presence and Scandal

Whereas one element of the concerns raised about presence in proximity to PAS-E has to do with the act of presence itself, another has to do with scandal. A consideration of scandal is necessary in cases wherein an action could lead another person into moral error, including even those cases when the action concerned is good or morally neutral. This latter is the problem that St. Paul draws attention to in his first letter to the Corinthians. While noting that there is nothing inherently wrong with eating food sacrificed to idols because “no idol in the world really exists” (1 Cor 8:7 NRSV, used throughout), Paul admonishes the Corinthians not to do so for the sake of those of weak conscience who might be led into error on witnessing such acts. So strong is Paul’s concern about scandal that he concludes, “if food is a cause of their falling, I will never eat meat, so that I may not cause one of them to fall” (1 Cor 8:13).

Accordingly, for Aquinas scandal occurs when one is “disposed to a spiritual downfall by another’s word or deed” insofar as, by “injunction, inducement or example,” such a word or deed moves them to sin. ²⁹ This definition is more precise than the popular usage of the word scandal, which tends to mean something like causing moral outrage or confusion. In Catholic ethics, for some action or other to be considered scandalous, it must have a demonstrably negative impact on the capacity for another’s conscience to choose the good. ³⁰ Crucially, this approach conceives of scandal in terms of occasions where the risk is present, rather than as acts that give scandal in and of themselves. ³¹ Whether or not scandal occurs depends on both the occasion for scandal and the moral agent who might be scandalized. As Angela Senander notes, an occasion for scandal “makes a sinful response more likely, but the person responding remains free not to sin.” ³²

In the case of presence in proximity to PAS-E, the occasion for scandal clearly arises whenever presence is offered as encouragement in the pursuit of PAS-E, especially when a moral authority encourages a person to end their life and all the more so if that encouragement ultimately forms part of that person’s choice to do so. In such cases, the morally illicit act of encouraging a person to enact PAS-E scandalizes precisely because it is morally illicit. ³³ Such an instance of scandal is not the issue under consideration here. The issue at hand is the case when the choice to be present is morally good in itself yet poses a risk of scandal. Should one refrain from doing something that is otherwise morally good if it gives rise to a risk of scandal?

Aquinas grapples with this issue in the Summa Theologica when answering the question of whether spiritual or temporal goods should be foregone on account of scandal. ³⁴ In response, he notes that the key concern here is what is known as the “scandal of the little ones”—scandal caused in others because of misunderstanding or a weak conscience on their part, the same concern Paul raised in addressing the Corinthians. ³⁵ To the case at hand, if one is a moral authority and their proximity to any aspect of PAS-E could be interpreted as endorsement, it could unintentionally provide a person with encouragement to go through with the act. In this context, we should observe that there are many cases in which presence at a particular place and moment in time is one and the same as encouragement, or at least reveals a favorable disposition toward what is happening. ³⁶ Samaritanus Bonus and the other commentators are right to identify and warn about this risk. Recalling Samaritanus Bonus’s approach, this risk is particularly poignant in the most salient moment of the process—when assisted suicide or euthanasia are enacted by ingestion or injection, a point at which one’s presence could easily be interpreted as complicity. Given the seriousness of leading another into sin, such scandal must be avoided.

However, a similar question to that which we considered above lingers here: Is it always and necessarily the case that the risk of scandal will be present? And is there anything that can be done to mitigate such a risk? In the first place, we should note that there are some cases in which it is very unlikely that one’s presence would be an occasion for scandal. Revisiting the examples of the Catholic chaplain who remains as protest or the Catholic physician who remains to provide an alternative, both of whom have well-known objections to PAS-E, establishing scandal in either case would require believing that their acts would lead someone to think that what they really believe is that PAS-E does not consist of serious evils and, on that basis, take up or promote PAS-E. Unless one is committed to misinterpreting these cases, it is difficult to construe them as occasions for scandal.

What of cases wherein one’s objection to PAS-E is less well known, or where there is a real possibility for ambiguity or misinterpretation of the choice to be present in order to to offer an alternative? Here we return to Aquinas. He argues that one should either conceal or delay spiritual or temporal goods if they will provide an occasion for scandal. ³⁷ Importantly, Aquinas does not suggest that the goods be withheld because they could or might create an occasion for scandal. Instead, he seeks alternative methods by which the good can be realized. ³⁸

Aquinas presents concealment as one option since a good offered discreetly cannot be misinterpreted, an approach that may have some bearing on the question at hand. However, I suggest that it is in Aquinas’s recommendation of deferment that we find the most pertinent advice. Aquinas sees deferment as a temporary measure that allows for explanation, holding that once the matter has been explained the scandal will cease. ³⁹ Explaining the morally sound rationale for one’s choice to be present, on this view, provides a necessary and adequate mitigation against the risk of scandal. Crucially, Aquinas argues that if the scandal does not cease following explanation, “it would seem to be due to malice.” ⁴⁰ As such, he declares it the “scandal of the Pharisees”: scandal stirred up by malice to hinder the good, which should be treated with contempt and have no bearing on whether or not a good is pursued. ⁴¹

With this in mind, we return to Samaritanus Bonus. The English translation of the letter leaves unclear the question of whether the CDF would be open to presence that is unlikely to be scandalous or presence for which the risk of scandal is mitigated through explanation. The other translations seem to categorically rule this possibility out, and Eijk and other commentators give the same impression. However, to hold such a position based on the risk of scandal is an incomplete use of the concept, which neither acknowledges that scandal is a risk rather than a necessary consequence of an action, nor that concealment or explanation are methods of mitigating this risk. In ruling out the possibility of being present on this basis, the potential to provide a spiritual and temporal good is correlatively closed off. Based on the understanding of scandal developed here and the discussion of the act of presence above, I advance a different conclusion in the next section. My focus is on the possibility of presence as providing an alternative.

Presence as a Witness to Hope and the Offer of an Alternative

In this section, I argue that the approach to end-of-life care articulated in Samaritanus Bonus anticipates certain circumstances in which a person providing care to someone who is pursuing PAS-E could judge that remaining present at various points of the PAS-E process is ethically justified. The argument forthwith assumes the position developed above: complicit presence is illicit at any part of the PAS-E process, as is presence that causes scandal. With that as background, my aim is to show that there are cases in which a caregiver’s choice to be present in proximity to PAS-E is consistent with Catholic ethics because that presence has as its object the provision of an alternative for the person. ⁴² I also note that such an object could be pursued at different times in the PAS-E process—from when a person is first considering PAS-E to after they have commissioned the act. Sound practical wisdom would be required to determine if and when this morally good form of presence could be offered in particular circumstances, which includes consideration of the increased ethical risk of scandal that occurs at the moment that PAS-E is enacted through ingestion or injection.

I begin an analysis of Samaritanus Bonus’s approach to end-of-life care by returning to the paragraph cited at the beginning of the preceding section. The wording below reflects the inclusion of “always” that is found in the German, Spanish, Italian, and French translations, and is missing in the English:

It is necessary to remain close to a person who may not be in the objective condition to receive the sacraments, for this nearness is always an invitation to conversion, especially when euthanasia, requested or accepted, will not take place immediately or imminently. Here it remains possible to accompany the person whose hope may be revived and whose erroneous decision may be modified, thus opening the way to admission to the sacraments. ⁴³

What is significant here is Samaritanus Bonus’s suggestion that nearness to a person is always an invitation to conversion. This view is striking in its contrast to that found in the paragraph that follows, which claims that presence always implies complicity. That said, the statement that nearness is always an invitation to conversion invites the same analysis developed above regarding the object of the act. Some kinds of nearness will constitute complicity with PAS-E, while some will not, and, correspondingly, may be morally good.

Further clarification on what would characterize the latter is provided by Samaritanus Bonus’s understanding of the Christian duty to provide care to those who are dying. Taking its lead from the parable of the Good Samaritan (Luke 10:25–37), who comes near to and takes responsibility for the man who is left half dead at the side of the road, Samaritanus Bonus upholds the Samaritan’s disposition as paradigmatic for care at the final stage of life. Seen as an exemplar of the Catholic tradition’s commitment to the unique dignity of each and every person, the Samaritan’s example leads to a universally applicable moral demand for Christians who are called to show care at this particularly difficult stage in life, and in so doing reflect the love of God to those whom they are caring for. ⁴⁴

Indeed, Samaritanus Bonus conceives of the parable as providing specific guidance on dispositions and behaviors that the Christian is called to in the context of end-of-life care:

The parable of the Good Samaritan shows what the relationship with the suffering neighbour should be, what qualities should be avoided—indifference, apathy, bias, fear of soiling one’s hands, totally occupied with one’s own affairs—and what qualities should be embraced—attention, listening, understanding, compassion, and discretion. ⁴⁵

And further:

The invitation to imitate the Samaritan’s example—“Go and do likewise” (Lk 10:37)—is an admonition not to underestimate the full human potential of presence, of availability, of welcoming, of discernment, and of involvement, which nearness to one in need demands and which is essential to the integral care of the sick. ⁴⁶

One can see in these paragraphs how the virtuous disposition of caring is expressed through a particular kind of presence, one which opens up the possibility of extending the love of Christ to the person who is close to death. Such an approach underpins one of the dominant themes of Samaritanus Bonus, “remaining” by the side of the person who is dying. In particular, the letter spends a substantial amount of time meditating on Christ on the cross as an illustration of Christ’s enduring proximity to all human suffering, especially where the advent of death is painful, meaningless, or unjust. As such, Samaritanus Bonus reflects that “the Love of God always makes itself known in the history of men and women, thanks to the love of the one who never deserts us, who remains, despite everything, at our side.” ⁴⁷ And later:

The experience of the Cross enables us to be present to the suffering person as a genuine interlocutor with whom to speak a word or express a thought, or entrust the anguish and fear one feels. To those who care for the sick, the scene of the Cross provides a way of understanding that even when it seems that there is nothing more to do there remains much to do, because remaining by the side of the sick is a sign of love and of the hope that it contains. The proclamation of life after death is not an illusion nor merely a consolation, but a certainty lodged at the center of love that death cannot devour. ⁴⁸

Founded on these reflections, Samaritanus Bonus holds together the good of remaining present and that of the condition of possibility for love and hope at the end of life. Someone who provides such loving presence is able to speak comfort “drawn from the compassion of Jesus on the Cross” that is “full of hope—a sincere hope, like Christ’s on the Cross, capable of facing the moment of trial and the challenge of death.” ⁴⁹ All of this underpins the letter’s vision of the dispositional commitments required for those who care for people at the end of life:

Those who assist persons with chronic illnesses or in the terminal stages of life must be able to know how to stay, to keep vigil, with those who suffer the anguish of death, to console them, to be with them in their loneliness, to be an abiding with that can instill hope. By means of the faith and charity expressed in the intimacy of the soul, the caregiver can experience the pain of another, can be open to a personal relationship with the weak that expands the horizons of life beyond death, and thus can become a presence full of hope. ⁵⁰

Crucially for the specific question being dealt with in this article, Samaritanus Bonus sees the provision of such care as even more urgent when it is offered to those who are pursuing PAS-E. The letter puts forward the position that the contemplation of suicide “is in many cases itself a symptom of disease, aggravated by isolation and discomfort.” ⁵¹ Such a situation provides an occasion with which the vision of care articulated above is most important, an opportunity in which “the Christian must offer to the sick the help they need to shake off their despair.” ⁵²

Not only does the letter maintain that such care is a good in itself, it also holds a profound hope for its effects: “A sick person, surrounded by a loving human and Christian presence, can overcome all forms of depression and need not succumb to the anguish of loneliness and abandonment to suffering and death.” ⁵³ And later: “The quality of love and care for persons in critical and terminal stages of life contributes to assuaging the terrible, desperate desire to end one’s life. Only human warmth and evangelical fraternity can reveal a positive horizon of support to the sick person in hope and confident trust.” ⁵⁴ It is on the basis of this approach that Samaritanus Bonus’s evocation to remain is extended with its full gravity to a person who may be pursuing PAS-E: “It is necessary to remain close to a person who may not be in the objective condition to receive the sacraments, for this nearness is always an invitation to conversion.” ⁵⁵ Indeed, remaining in this way is a matter of urgency, because it has the potential to effect a conversion of heart that is of enormous spiritual and temporal significance: helping a person choose a path other than PAS-E.

Importantly, what is put forward by Samaritanus Bonus as a pathway to such a conversion is not a form of fraternal correction in the abstract. The primary need identified is not explaining to the person pursuing PAS-E that the action is intrinsically evil. Instead, one is given a model of coming near to a person, suffering with them, and remaining as a loving presence at their side, based on the understanding that “human warmth and evangelical fraternity can reveal a positive horizon of support to the sick person in hope and confident trust.” ⁵⁶

In this way, Samaritanus Bonus echoes Francis’s calls for the church and her ministries to exemplify accompaniment, in which the church moves from exhortation of conscience through the clarification of principles to an accompaniment that transforms through loving presence. Such accompaniment is inspired by “God’s indulgent love” that “always accompanies our human journey; through grace, it heals and transforms hardened hearts, leading them back to the beginning through the way of the cross.” ⁵⁷ Accompaniment thus means removing “our sandals before the sacred ground of the other (cf. Ex 3:5),” with the goal of “making present the fragrance of Christ’s closeness and his personal gaze.” ⁵⁸ This gaze follows the example of Christ, who “looked upon the women and men whom he met with love and tenderness, accompanying their steps in truth, patience and mercy as he proclaimed the demands of the Kingdom of God.” ⁵⁹ In this way, the accompanying care called for is “steady and reassuring, reflecting our closeness and our compassionate gaze which also heals, liberates and encourages growth in the Christian life.” ⁶⁰

Given this understanding of accompaniment resting alongside all that Samaritanus Bonus has said, I argue that a person providing care to someone pursuing physician-assisted suicide could judge that its evocation to remain holds forth during—and indeed after—the PAS-E process. I put forward four reasons for this.

The first is that the letter makes clear there are no aspects of human experience in which the love of God cannot break through, and that includes the situation of the presence of a person who is in the process of making an erroneous decision. I have already shown that presence is not one and the same as complicity, and if a loving presence is offered to a person who is contemplating PAS-E, one increases the possibilities that the person will experience a conversion of heart and choose otherwise. The provision of such a presence should thereby be seen for its full significance as both a spiritual and temporal good. These points should be noted alongside contextual considerations about how PAS-E is pursued by an individual in the first place. Consider again the Victorian context, and a person who is in possession of the lethal drug. If the person chooses to end their life in this way, they consume the substances in a prescribed order and at a time and place of their choosing. In such a context, a person may decide not to continue even after they have actively started consuming the preparatory drugs. If a caregiver judges that their presence carries with it a hope of an alternative but leaves too early on account of the suggestion that presence can only be complicity, lost is the possibility of revealing “a positive horizon of support to the sick person in hope and confident trust.”

It is important to consider whether this applies even at that most salient moment of the process, when assisted suicide or euthanasia is performed through ingestion or injection. Care and caution are needed here, noting Samaritanus Bonus’s warning that the ethical risk of scandal is much higher at this moment. In some cases, individuals who have reached this point will be firmly and finally resolved in their decision to go through with the act. Where this is clearly the case, the circumstances will lead one to determine that their presence to provide an alternative would not be prudent, all things considered, because the circumstances render the object of that presence impossible. That said, in light of what has been developed above, I argue that there will be cases in which a caregiver judges that such presence at this time is morally licit or even required, especially if the person they are caring for has any level of ambiguity about their resolve to take the final step in PAS-E. After all, once one has started consuming the lethal drug, there is still the possibility that they will choose otherwise, and end up consuming too little to cause death, or spitting it out altogether. These alternate pathways could still be supported by the kind of presence encouraged by Samaritanus Bonus, and that this moment is so significant makes it all the more important to consider this.

The second reason follows here and is founded in Samaritanus Bonus’s very clear theological vision that the love of God knows no bounds, “thanks to the love of the one who never deserts us, who remains, despite everything, at our side,” ⁶¹ and its evocative suggestion that “even when it seems that there is nothing more to do there remains much to do, because remaining by the side of the sick is a sign of love and of the hope that it contains.” ⁶² Read as a whole, Samaritanus Bonus is at pains to make this unconditional proximity of Christ clear. Recall that the dispositions for the care of the sick include a willingness to be present to them even in the darkest moments, including where there is a risk of “soiling one’s hands.” ⁶³ This language echoes a well-known warning from Francis in Amoris Laetitia:

I understand those who prefer a more rigorous pastoral care which leaves no room for confusion. But I sincerely believe that Jesus wants a Church attentive to the goodness which the Holy Spirit sows in the midst of human weakness, a Mother who, while clearly expressing her objective teaching, always does what good she can, even if in the process, her shoes get soiled by the mud of the street. ⁶⁴

On the basis of this very clear missionary demand to take the love and hope of God into the most difficult places, and to do what good is possible even in complex situations, I argue that a person providing care to someone pursuing PAS-E may have good reason to judge that the object of instilling hope and the possibility of an alternative through presence is consistent with the vision for end-of-life care in Samaritanus Bonus, as well as with Pope Francis’s approach to pastoral accompaniment.

The third reason that presence with the object of providing an alternative is justified is that in some circumstances a person who has taken the final step in the PAS-E process will still need end-of-life care and may experience a conversion of heart after the act itself. Though this might seem a peculiar claim, recall the contextual information I provided earlier, and in particular the data from Oregon and Washington about the sometimes significant timeframes between ingestion, coma, and death. Moreover, even in the cases of shorter timeframes, the person concerned could need the kind of comforting physiological care that Samaritanus Bonus so strongly advocates for, and that need would be exacerbated when coma and death come slowly. Are they ineligible for this, because of the erroneous choice they have made? Surely not: the quality of one’s moral decision-making is not a criterion for receiving such care.

Turning to the context of the spiritual and moral life, we can ask whether it is possible that in the time between ingesting the drug and coma a person could experience sincere regret, repentance, and a conversion of heart. ⁶⁵ Though the effect of the act might not be reversible, it is traditional Catholic teaching that forgiveness is always available to those who sincerely repent and seek it. ⁶⁶ My focus is not on the question of admission to the sacraments; however, in Samaritanus Bonus’s section on this topic the letter invites priests to look for signs of repentance even from patients who have lost the capacity to communicate or who are in the process of falling unconscious: “the priest could administer the sacraments to an unconscious person sub condicione if, on the basis of some signal given by the patient beforehand, he can presume his or her repentance.” ⁶⁷ What if the opportunity to witness, encourage, and respond to such a conversion of heart is missed, because no one remains? On this basis, even if one comes to the conclusion that being present at the time of ingestion or injection in a particular case is not justified on account of the risk of scandal, the possibility of presence post-act should still be considered. This would reflect a sound application of Aquinas’s suggestion that goods might be delayed, but not withdrawn, on account of the risk of scandal.

This last point is grounded in one of Samaritanus Bonus’s principal claims: God’s love knows no boundaries. Like the father of the prodigal Son (Luke 15:11–32), it remains—always looking with hope for God’s beloved children to return and running to greet them when they do. Like the Good Samaritan, it goes to those in need, wherever they are, to provide care that is needed and reflects the healing ministry of Jesus. This is what impels a disposition that refuses “to underestimate the full human potential of presence, of availability, of welcoming, of discernment, and of involvement, which nearness to one in need demands and which is essential to the integral care of the sick.” ⁶⁸ Such a disposition, and the commitment to presence that flows from it, is good, and should be considered as a possibility for those offering care to someone who is pursuing PAS-E.

Fourth and finally, consistent with the preceding section I argue that such a commitment expressed in this way need not be an occasion for scandal. In some cases, this will be because of a caregiver’s well-known objection to PAS-E and their rationale for being present. In other cases, the risk of scandal may still be present, but the fact that an occasion for scandal could or might exist is insufficient for withholding the spiritual and temporal goods at stake. Instead, it calls for clear explanation on the part of the person making the choice to be present. As we have seen with Aquinas, such explanation does away with scandal and—if it does not—one should consider whether malice in those taking scandal is to blame. In such a situation, this “scandal of the Pharisees” need not hold any weight in the caregiver’s decision-making.

All of those who provide care to a person at the end of their life need to discern how best to remain near to the people they are caring for. As I hope I have demonstrated in this and the preceding sections, it is consistent with traditional Catholic ethics and the vision for end-of-life care articulated in Samaritanus Bonus that they include the possibility of remaining as one option for the provision of their care for those who are seeking PAS-E, even at the most salient moments in that process. For this reason, while noting my full agreement with the warning that presence in proximity to PAS-E “could” or “might” constitute or be interpreted as complicity, I respectfully argue that this position needs refinement, because this is not always and necessarily the case. It would be a tragedy if spiritual and temporal goods are withheld from those who could benefit from them because of incomplete guidance on this matter.

Conclusion

Catholic chaplains and clinicians who exercise their vocations in contexts wherein PAS-E is legal may need to confront the difficult question of whether or not their presence during the process, including at its most salient moments, is consistent with Catholic ethics. Debate on this question to date has rightly warned against any form of complicit presence and has highlighted the risk of scandal. Taking these issues as given, I have argued that presence should be understood according to traditional tools for analyzing moral acts, and that scandal should be approached similarly, drawing in particular on Aquinas. Were one to choose to be present in order to provide an alternative to PAS-E in circumstances in which this would be justifiable, I have argued that such a choice is consistent with Catholic ethics and, with appropriate explanation, is not an occasion for scandal. Indeed, as I have shown, in some cases it could be an expression of the noble and challenging vision of end-of-life care articulated in Samaritanus Bonus—which remains, despite everything, at the side of the dying person.