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Mike Humphrey wrote:

Hi, guys —

I found the following misconceptions on "End of Life" issues in my weekly parish bulletin.

Ethical Decision Making At End-Of-Life — Misconceptions

Some misconceptions exist among Catholics regarding Church teaching on end-of-life issues. These misconceptions include:

  1. When faced with natural death, one must seek and accept all life-support measures.
  2. Once a life-saving technique has been started, it can never be shut off.
  3. Should a dying person go into heart failure, Catholics may not refuse artificial resuscitation by means of Do Not Resuscitate (DNR) orders.
  4. Catholics may never refuse artificial nutrition and hydration, no matter what form it may take.
  5. Because pain is a fact of life and can be offered up for a religious purpose, good pain medication practices are not important.
I have questions about some of these statements.
  • Are they correct?

Mike

  { Are these End-of-Life misconception issues I found in my parish bulletin correct? }

Richard replied:

Hi, Mike —

Yes, all of those statements deviate in some way from Church teaching, so they are misconceptions.

  1. When faced with natural death, one must seek and accept all life-support measures.
    [ top ]

    • The first one is definitely erroneous. Evangelium Vitae paragraph 65 has a useful explanation of what constitutes euthanasia, what distinguishes euthanasia from a decision to forego aggressive medical treatment, and why it is not mandatory to pursue all forms of life support:

      65. For a correct moral judgment on euthanasia, in the first place a clear definition is required. Euthanasia in the strict sense is understood to be an action or omission which of itself and by intention causes death, with the purpose of eliminating all suffering. "Euthanasia's terms of reference, therefore, are to be found in the intention of the will and in the methods used".[76]

      Euthanasia must be distinguished from the decision to forego so-called "aggressive medical treatment", in other words, medical procedures which no longer correspond to the real situation of the patient, either because they are by now disproportionate to any expected results or because they impose an excessive burden on the patient and his family. In such situations, 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".[77] Certainly there is a moral obligation to care for oneself and to allow oneself to be cared for, but this duty must take account of concrete circumstances. It needs to be determined whether the means of treatment available are objectively proportionate to the prospects for improvement. 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.[78]

      So Catholic ethics do not require anyone to seek and accept all life-saving measures. This question is also addressed at length by the Declaration on Euthanasia:

      Everyone has the duty to care for his or her own health or to seek such care from others. Those whose task it is to care for the sick must do so conscientiously and administer the remedies that seem necessary or useful.

      • However, is it necessary in all circumstances to have recourse to all possible remedies?

      In the past, moralists replied that one is never obliged to use "extraordinary" means. This reply, which as a principle still holds good, is perhaps less clear today, by reason of the imprecision of the term and the rapid progress made in the treatment of sickness. Thus, some people prefer to speak of "proportionate" and "disproportionate" means. In any case, it will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities 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.

      In order to facilitate the application of these general principles,
      the following clarifications can be added:

      1. If there are no other sufficient remedies, it is permitted, with the patient's consent, to have recourse to the means provided by the most advanced medical techniques, even if these means are still at the experimental stage and are not without a certain risk. By accepting them, the patient can even show generosity in the service of humanity.

      2. It is also permitted, with the patient's consent, to interrupt these means, where the results fall short of expectations. But for such a decision to be made, account will have to be taken of the reasonable wishes of the patient and the patient's family, as also of the advice of the doctors who are specially competent in the matter.

        The latter may in particular judge that the investment in instruments and personnel is disproportionate to the results foreseen; they may also judge that the techniques applied impose on the patient strain or suffering out of proportion with the benefits which he or she may gain from such techniques.

      3. It is also permissible to make do with the normal means that medicine can offer. Therefore one cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community.

      4. When inevitable death is imminent in spite of the means used, it is permitted in conscience to take the decision to 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. In such circumstances, the doctor has no reason to reproach himself with failing to help the person in danger.

  2. Once a life-saving technique has been started, it can never be shut off. [ top ]

    • The Catechism addresses this point. Paragraph 2278 affirms that, in certain circumstances, it is permissible to discontinue life-sustaining treatment:

      2278 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. Here one does not will to cause death; one's inability to impede it is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected.

      The Vatican has an office for medical ethics issues, called the Pontifical Council for Pastoral Assistance to Health Care Workers. While the Council does not exercise teaching authority, it does give helpful moral guidance and explanation for the Catholic position on this question in its Charter for Health Care Workers.

      Contemporary medicine, in fact, has at its disposal methods which artificially delay death, without any real benefit to the patient. It is merely keeping one alive or prolonging life for a time, at the cost of further, severe suffering. This is the so-called "therapeutic tyranny," which consists "in the use of methods which are particularly exhausting and painful for the patient, condemning him in fact to an artificially prolonged agony."

      This is contrary to the dignity of the dying person and to the moral obligation of accepting death and allowing it at last to take its course. "Death is an inevitable fact of human life": it cannot be uselessly delayed, fleeing from it by every means

  3. Should a dying person go into heart failure, Catholics may not refuse artificial resuscitation by means of Do Not Resuscitate (DNR) orders.[ top ]

    • So far, I have not found any mention of "Do Not Resuscitate orders" in official church documents. However, the explanation above about foregoing aggressive medical treatments does seem to apply to resuscitation. In situations where a patient's condition is declining despite resuscitation, it seems reasonable to consider the resuscitation as an unproductive treatment, and it is permissible to forego it, if the patient wants.

  4. Catholics may never refuse artificial nutrition and hydration, no matter what form it may take. [ top ]

    • The Congregation for the Doctrine of the Faith gave some clear teaching on this question at the request of the U.S. bishops in 2007:

      The administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life. It is therefore obligatory to the extent to which, and for as long as, it is shown to accomplish its proper finality, which is the hydration and nourishment of the patient. In this way suffering and death by starvation and dehydration are prevented.

      In short, as long as food and water help to keep the patient alive or comfortable, they are morally required. This is the case even when artificial means are employed such as feeding tubes or IV lines. But if the food and water are no longer effective for those purposes, they may be discontinued.

      For further explanation about this point, you can see the Commentary issued by CDF along with their letter to the U.S. bishops.

  5. Because pain is a fact of life and can be offered up for a religious purpose, good pain medication practices are not important. [ top ]

    • That statement, of course, expresses a callous attitude utterly contrary to the Catholic spirit of mercy, which calls on us to "comfort the afflicted".

      This question pertaining to painkillers is also addressed by the magisterium in several places, one of which is in the Declaration on Euthanasia. While it is praiseworthy if a patient chooses to voluntarily limit his use of painkillers in order to consciously share in the Lord's sufferings, he is not required to do so at all, and we should assume that patients want the use of available painkillers unless they decide otherwise:

      In modern medicine, increased attention is being given to what are called "methods of palliative care", which seek to make suffering more bearable in the final stages of illness and to ensure that the patient is supported and accompanied in his or her ordeal. Among the questions which arise in this context is that of the licitness of using various types of painkillers and sedatives for relieving the patient's pain when this involves the risk of shortening life. While praise may be due to the person who voluntarily accepts suffering by forgoing treatment with pain-killers in order to remain fully lucid and, if a believer, to share consciously in the Lord's Passion, such "heroic" behavior cannot be considered the duty of everyone. Pius XII 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" . 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.

      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. Therefore, one must not be surprised if some Christians prefer to moderate their use of painkillers, in order to accept voluntarily at least a part of their sufferings and thus associate themselves in a conscious way with the sufferings of Christ crucified (cf. Matthew 27:34). Nevertheless it would be imprudent to impose a heroic way of acting as a general rule. On the contrary, human and Christian prudence suggest for the majority of sick people the use of medicines capable of alleviating or suppressing pain, even though these may cause as a secondary effect semi-consciousness and reduced lucidity. As for those who are not in a state to express themselves, one can reasonably presume that they wish to take these painkillers, and have them administered according to the doctor's advice.

    [ top ]

 — Richard Chonak

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