Awareness of Catholic moral principles can help us navigate difficult questions regarding appropriate medical treatment in long-term care and terminal illness.
CONSIDER THESE RECENT NEWS ITEMS:
Vincent Lambert, a 42-year old Frenchman who had been severely disabled, brain damaged, and minimally conscious for more than a decade after a motorcycle accident, was effectively euthanized by starvation in July after doctors removed his feeding tube following a protracted court battle involving family members and medical professionals.
In Ontario, Canada, 27-year old Idan Azrad suffered a traumatic head injury in August and was declared brain dead. Azrad’s family arrived from Israel and transported him to a long-term care facility back home, as Orthodox Jews believe death occurs only when the heart stops.
In British Columbia, 41-year old Sean Tagert, who required a ventilator full time due to amyotrophic lateral sclerosis (ALS), applied for and received a “medically-assisted death” in August, saying he could neither find nor afford the 24- hour nursing care he needed. “I’m just done, worn-out,” he wrote in a Facebook post announcing his request.
These high-profile cases raise troubling ethical questions regarding treatment options for individuals with terminal illnesses or grave injuries with little or no hope of recovery. Many of the same questions also surface daily in hospitals, long-term care facilities, and hospice situations everywhere — and sometimes even within our own families.
We know, of course, that “medically-assisted death” (also called assisted suicide, now legal in several U.S. states and in Canada) and euthanasia are never a moral option. But what medical interventions are we morally obligated to undertake in order to sustain life? Under what circumstances can artificial life support be refused or withdrawn? Who rightfully decides this? And what can we do to prepare for the possibility that we might face such difficult decisions in the future?
Such questions likely would arise while we are forced to process a tremendous amount of information at a time of great emotional stress amid conflicting personal and professional opinions. Understanding Catholic moral principles can enable us to clear away much confusion so as to make prudent and informed decisions.
Ordinary vs. extraordinary measures
In evaluating medical treatment options, moral theologians distinguish between “ordinary” measures and “extraordinary” measures — those that are morally obligatory and those that are morally optional.
“The natural law and the Fifth Commandment require that all ordinary means be used to preserve life, such as food, water, exercise, and medical care,” writes Colin B. Donovan, vice president for theology at EWTN. “Since the Middle Ages, however, Catholic theologians have recognized that human beings are not morally obligated to undergo every possible medical treatment to save their lives” — under certain limited circumstances, “even very ordinary ones.”
Generally speaking, an extraordinary measure is a medical procedure that offers little hope of benefit and is excessively burdensome to the patient. “Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of ‘over-zealous’ treatment,” states the Catechism of the Catholic Church. “Here one does not will to cause death: one’s inability to impede it is merely accepted.” (#2278)
We don’t have to sustain life at all costs, because ultimately death is inevitable; we were created not just for this life, but for eternal life. At the same time, we cannot cause or intend death; we can only allow the natural process of death to continue.
“When a person has an underlying terminal disease, or their heart, or some other organ, cannot work without mechanical assistance, or a therapy being proposed is dangerous, or has little chance of success, then not using that machine or that therapy results in the person dying from the disease or organ failure they already have,” Donovan explained. “The omission allows nature to takes its course. It does not directly kill the person, even though it may contribute to the person dying earlier than if aggressive treatment had been done.”
Nutrition and hydration
Sometimes the suggestion is made to allow a patient to die by removing a gastric feeding tube, their only source of food and water.
In 2004, Pope John Paul II said that “the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act.” In principle, he went on, it should be considered ordinary and proportionate care “and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering.”
The last part of the pope’s statement is key. The purpose of food and water is to provide nutrition and to reduce pain. Although in principle morally obligatory, nutrition and hydration can be discontinued if they no longer fulfill these purposes.
Donovan describes a situation where withdrawing food and water could be permissible: “In the last hours, even days, of a cancer patient’s life, or if a sick person’s body is no longer able to process food and water, there is no obligation to provide nutrition and hydration. The patient will die of their disease or their organ failure before starvation or dehydration could kill them.”
The distinction remains between intentionally killing the patient through lack of nutrition or allowing the person to die of the disease, he noted.
In long-term care and in terminal cases, it is important to ease the suffering of the patient through palliative care. Complicating this endeavor is that some pain medications have sedative effects and, in some instances, can speed up the dying process.
The U.S. bishops’ Ethical and Religious Directives for Catholic Health Care Services (ERD), which provides moral guidance for medical professionals, states that terminal patients should be kept free of pain so that they can die in comfort and with dignity. However, it cautions that in order to allow the patient to properly prepare for death, the patient “should not be deprived of consciousness without a compelling reason.”
That primarily means spiritual preparation — the opportunity to receive the sacraments of the Church and to reconcile with loved ones.
The prudent use of pain-management medications remains licit “even if this therapy may indirectly shorten the person’s life so long as the intent it not to hasten death,” the ERD says.
Theologically, death is the separation of body and soul, but how can we know when that happens?
Death is certain when heartbeat and respiration cease and the patient cannot be revived. More controversial is the declaration of death through neurological criteria. The American Medical Association defines brain death bluntly: “An individual with irreversible cessation of all functions of the entire brain, including the brain stem, is dead.”
According to the National Catholic Bioethics Center, the Catholic Church accepts this definition of death. “The complete and irreversible loss of all brain function may be taken as a reasonable indicator that the rational soul is no longer present,” says a statement by NCBC ethicists.
That’s not to be confused with “persistent vegetative state” (PVS). “PVS often involves brain damage, but never death of the whole brain,” explains Father Tad Pacholczyk, NCBC’s director of education. “Genuinely brain-dead individuals never ‘wake up.’ Patients in a PVS occasionally do.”
PVS patients “are not dead,” he stressed.
Accurate determination of brain death can only be made after a thorough battery of tests repeated at intervals and confirmed by other studies such as an EEG. A brain-dead patient who is kept on a ventilator might seem alive but cannot breathe on his or her own, he noted. Even with a ventilator, the patient’s organs will normally begin failing within a few days.
Treatment decisions ideally should be made by the patient, if competent, or “by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected,” the Catechism explains.
An individual might establish advance medical directives to govern end-of-life care. These legal documents come in three main types: a living will, a POLST or “Physician Order for Life Sustaining Treatment,” or the appointment of a health care agent or proxy.
In a living will, the individual lists treatment options to be accepted or rejected under particular circumstances. NCBC ethicists, however, discourage their use. “No matter how well-crafted, such a document can never predict all the possible problems that may occur at a later time or anticipate all future treatment options,” they say in a statement. “A living will can be misinterpreted by medical providers who might not understand the patient’s wishes.”
A POLST provides medical orders allowing health care providers to make these end-of life decisions. These documents vary from state to state, and state Catholic conferences thus have varied opinions on them. For example, whereas the California Catholic Conference calls POLST “a valuable tool,” the Minnesota Catholic Conference says the POLST paradigm “cannot be fully reconciled with a Catholic framework for end-of-life decisions.”
The NCBC highly recommends the third type of advance directive, called a “power of attorney for health care” or a “health care proxy,” and suggests Catholics appoint a trusted individual who understands the moral issues to make treatment decisions for them in the event they are unable to do so themselves.
“In choosing an agent or proxy, a person can declare in writing that all treatment and care decisions made on their behalf must be consistent with and not contradict the moral teachings of the Catholic Church,” said the NCBC statement.
GERALD KORSON is a Legatus magazine staff writer
CATHOLIC RESOURCES ON LIFECARE
Ethical and Religious Directives for Catholic Health Care Services (USCCB):
- http://www.usccb.org/about/doctrine/ethical-and-religious-directives/ upload/ethical-religious-directives-catholic-health-service-sixthedition-2016-06.pdf
Palliative and Hospice Care: Caring Even When We Cannot Cure (Catholic Health Association):
Killing the Pain, Not the Patient: Palliative Care vs. Assisted Suicide (USCCB):
- http://www.usccb.org/about/pro-life-activities/respect-life-program/killingthe-pain.cfm Guide to State-by-State Resources: https://www.catholicendoflife.org/resources/