The twilight of a Christian’s life should be a hopeful time. As death approaches, however, we confront not only eternity, but also many thorny moral issues that naturally arise at life’s end.

In short, the Catholic patient wonders: How do I respect life even as I am dying? Here are some answers to frequently asked questions, drawn from the teachings of the Church.

Q. What are the non-negotiables?

A. The Church is very clear that some actions — such as euthanasia — are intrinsically evil and may never be pursued.

In 1980, the Congregation for the Doctrine of Faith released its “Declaration on Euthanasia,” in which it defined euthanasia as “an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated. Euthanasia’s terms of reference, therefore, are to be found in the intention of the will and in the methods used.”

We should note that euthanasia can be accomplished passively or actively. In passive euthanasia, an act of omission, such as withholding food and water, brings about a person’s death.

Active euthanasia, on the other hand, is defined by an act of commission such as the injection of a lethal dose of potassium chloride, insulin or another drug.

Physician-assisted suicide is a kind of self-euthanasia. It shares with active euthanasia the intent to kill the patient, but differs in that the patient, not the physician, performs the act that ends life.

Usually, as in the state of Oregon, where physician-assisted suicide is now legal, physicians provide patients with a prescription for a lethal dose of barbiturate.

Partisans of euthanasia and its cousin, physician-assisted suicide, argue that it is cruel to let people suffer or prevent them from making their own decision to end their own lives. The hidden assumption in most arguments supporting eu-thanasia is that there is such a thing as what the Nazis dubbed “life un-worthy of life.”

In contrast, the Catechism of the Catholic Church teaches:

“Human life is sacred because from its beginning it involves the creative action of God and it remains forever in a special relationship with the Creator, who is its sole end. God alone is the Lord of life from its beginning until its end: no one can under any circumstance claim for himself the right directly to destroy an innocent human being” (No. 2258, emphasis in original).

Lives that either do not manifest certain elements of consciousness or are racked by intractable pain do not deserve less respect and care, but rather more. For the Catholic, there is no such thing as “life unworthy of life.”

As the Catechism reminds us, “Those whose lives are diminished or weakened deserve special re-spect” (No. 2276).

Q. What options are available to those suffering from intractable pain?

A. Aside from euthanasia, the end-of-life patient is often engaged with questions regarding the morality of refusing treatment, accepting analgesia and myriad other ethical questions. When a person is tempted to seek an end to his pain by ending his life, other morally appropriate options are available.

In Evangelium Vitae (EV), Pope John Paul II took up the question of palliative care, treatment aimed at reducing or eliminating pain when cure is no longer in sight.

He called the person “heroic” who would forgo treatment with painkillers in order to remain “fully lucid” and “share consciously in the Lord’s passion.” Nevertheless, he acknowledged that this is not the duty of all.

Rather, with Pope Pius XII, Pope John Paul affirmed that it is “licit to relieve pain by narcotics, even when the result is decreased consciousness and a shortening of life, ‘if no other means exist, and if, in the given circumstances, this does not prevent the carrying out of other religious and moral duties'” (EV, No. 65).

Q. If their side effects include shortening life, how, according to Church teaching, is using painkillers different from suicide?

A. Pope John Paul anticipated this question and wrote: “In such a case, death is not willed or sought, even though for reasonable motives one runs the risk of it: there is simply a desire to ease pain effectively by using the analgesics which medicine provides. All the same, ‘it is not right to deprive the dying person of consciousness without a serious reason’: as they approach death people ought to be able to satisfy their moral and family duties, and above all they ought to be able to prepare in a fully conscious way for their definitive meeting with God” (No. 65).

Suffice it to say that the Vatican has issued no “list of duties” that must be fulfilled before analgesia should be implemented. Certainly family circumstances might include preparing or finalizing a will, or asking a loved one’s forgiveness for wrongdoing.

Moreover, if analgesic medications were used with the intention of shortening life, or if a greater dose than needed to ease pain was used to hasten death, such an act would indeed be euthanasia or physician-assisted suicide.

In any case, the Catholic must prayerfully consider his state of af-fairs and intention, consult a trusted, orthodox adviser and ensure that his conscience is well-informed by Church teaching in order to decide whether analgesia would be right for his circumstances.

Q. Is refusing treatment the same as passive euthanasia’s act of omission?

A. There is a common misconception that holds that all Catholics must end their lives on ventilators. This is simply untrue. And while refusing or withholding a treatment can be a morally evil act of omission, there are circumstances in which this is not the case.

The “Declaration on Euthanasia” acknowledges that persons have a duty to care for their own health. At the same time, it distinguishes between ordinary and extraordinary treatments. We have a moral obligation to accept the former, but it is morally legitimate to refuse the latter.

Pope John Paul explicitly states that “to forego extraordinary or disproportionate means is not the equivalent of suicide or euthanasia; it rather expresses acceptance of the human condition in the face of death” (EV, No. 65).

Quoting the “Declaration on Euthanasia,”Pope John Paul wrote, “When death is clearly imminent and inevitable, one can in conscience ‘refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted'” (No. 65).

Normal, ordinary care can be thought of as what meets a person’s basic needs, such as food, hygiene, shelter and clothing. Treatments are obligatory when they offer a reasonable hope of benefit to a patient without undue burden.

The declaration notes that a correct judgment about whether a means is extraordinary (not obligatory) or ordinary (obligatory) can be made by “studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibility of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources.”

Q. What would be some specific examples of ordinary and extraordinary care?

A. A paralyzed patient, for ex-ample, could not rightly refuse repositioning, which lessens the probability of developing bedsores. Such a refusal would inevitably lead to development of an infected bedsore and eventual death from infection.

Repositioning offers a reasonable benefit to the patient. It’s something a person naturally does when seated or lying down as a way of preventing bedsores. When unable, a person must have someone do it for him.

Or consider another example: On the one hand is someone who is dying of lung cancer and has tried all available, effective treatments. His lungs are so destroyed that they hardly get the oxygen from the air into his blood stream.

A ventilator here might prove burdensome to the patient. He is at the end of his life and a ventilator will not reverse the natural history of his disease, nor provide a window of time in which he can get another effective treatment. That kind of extraordinary care would not be obligatory.

On the other hand, consider the otherwise healthy nursing-home resident who gets a lung infection that reduces his ability to breathe so much that without antibiotic treatment he will die. A ventilator here would be a proportionate treatment (and thus obligatory) because it would boost his lung function enough to keep him alive long enough for the antibiotics to work.

Just because he is older does not mean he can rightly refuse a treatment that will help him continue to live out his days.

As these examples illustrate, the distinction between obligatory and non-obligatory treatment is case specific. There are many reasons why someone could legitimately refuse treatment, including excessive burdensomeness, pain, cost or side effects. Again, consulting someone with expertise in these matters is invaluable.

In short, while euthanasia and physician-assisted suicide are intrinsically evil, using painkillers or refusing extraordinary treatment can be morally legitimate. A well-formed conscience is necessary to discern the legitimacy of refusing treatment or accepting life-shortening analgesia.

Patrick C. Beeman, a medical student at the University of Toledo, is president of the Catholic Medical Students Association. He is a Pellegrino Fellow at Georgetown University Center for Clinical Bioethics.