Euthanasia and Extraordinary Care

 
Since the mid-20th century, the Catholic Church has strived to give the clearest guidance possible regarding the usage of life-support systems. Much of the teaching has been delivered in the context of the teaching on the immorality of euthanasia. Pope Pius XII, who witnessed and condemned the eugenics and euthanasia programs of the Nazis, was the first to explicate clearly this moral area and provide guidance. In 1980, the Sacred Congregation for the Doctrine of the Faith released its Declaration on Euthanasia which further clarified this guidance, especially in light of the increasing complexity of life-support systems and the promotion of euthanasia as a valid means of ending life. More recently, Pope John Paul II in his encyclical Evangelium Vitae (#64) affirmed these teachings and warned against the alarming symptoms of the culture of death... which sees the growing number of elderly and disabled people as intolerable and too burdensome. The Catechism (#2276-2279) also provides a succinct explanation of our Catholic teaching on this subject. Further guidance concerning the feeding and hydration of individuals particularly those in comas or persistent vegetative states has been addressed by the Pennsylvania Catholic Bishops (Nutrition and Hydration: Moral Considerations (1991)), the National Conference of Catholic Bishops (Ethical and Religious Directives for Catholic Health Care Services (1994)), and the United States Bishops Prolife Committee (Nutrition and Hydration: Moral and Pastoral Reflections (1993)). Many solid, Catholic moral theologians, including Dr. William May, Msgr. William Smith, Dr. Germain Grisez, and Bishop James McHugh, have also offered guidance on this issue in concert with the Magisterium.

Before addressing the intricacies of the feeding and hydration of individuals, particularly those in comas or persistent vegetative states (PVS), we must first remember some basic Catholic moral principles: First, the Catholic Church holds as sacred both the dignity of each individual person and the gift of life. We respect the sacredness of the continuum of life from conception until death. We must also have a respect and a vision not only for life here and now on this planet and in this time frame, but also for eternal life, hopefully with Almighty God in Heaven. Therefore, each person is bound to lead his life in accord with Gods plan and with openness to His will, looking to lifes fulfillment in Heaven.

Second, the care for our lives is not a matter of mere physicalism where we focus so much on the body and the physical life that we lose sight of the soul and the spiritual life of the individual. Consequently, we must weigh whether a treatment is simply keeping a body functioning and postponing death versus assisting in the strengthening of life and restoring health. We must recognize that the time comes for us to depart from this life and return to our Lord in a new life.

Third, we believe that each person is bound to use ordinary means of caring for personal health. Here one would think of basic care, which obviously includes proper nourishment and hydration food and water and ordinary medial care common medical treatments. Ordinary means would be those which offer reasonable hope of benefit and are not unduly burdensome to either the patient or the family.

A person may, but is not bound to, use extraordinary means those means which primarily are not considered ordinary care or common medical treatments. These means do not offer reasonable hope of benefit and may be excessively burdensome to either the patient or the family. Factors to consider in determining whether a treatment is extraordinary include the type of treatment, the degree of complexity, the amount of risk involved, its cost and accessibility, and the state of the sick person and his resources. One would weigh the proportion of pain and suffering against the amount of good to be done. Granted, in our world today, exactly what constitutes extraordinary medical care becomes harder and harder to define. For instance, accepting an artificial heart is clearly experimental and would be extraordinary, whereas the usage of a respirator or ventilator is oftentimes a standard procedure to aid the patients recovery.

Fourth, the purposeful taking of the life of an innocent person is a grave, mortal sin. Vatican Council II condemned all offenses against life itself, such as murder, genocide, abortion, euthanasia, and willful suicide... Gaudium et Spes, #27). Euthanasia, literally translated as good death or easy death, is an action or omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated (Declaration on Euthanasia). In other words, euthanasia involves the purposeful termination of life by a direct action, such as lethal injection, or by an omission, such as starvation or dehydration. Note that euthanasia is commonly known as mercy killing : this term is most appropriate because the act involves an intentional killing, no matter how good the intention may be to alleviate suffering. Pope John Paul II also asserted that euthanasia involves a false mercy, a perversion of mercy: true compassion leads to sharing anothers pain; it does not kill the person whose suffering we cannot bear (Evangelium Vitae, #66). Therefore, the Holy Father confirmed, Taking into account these distinctions, in harmony with the Magisterium of my Predecessors and in communion with the bishops of the Catholic Church, I confirm that euthanasia is a grave violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person (#65).

However, euthanasia must be distinguished from the stopping of extraordinary means of health care or other aggressive medical treatment. The patient or guardian in the case of an unconscious patient has the right to reject outright or to discontinue those procedures which are extraordinary, no longer correspond to the real situation of the patient, do not offer a proportionate good, do not offer reasonable hope of benefit, impose excessive burdens on the patient and his family, or are simply heroic. Such a decision is most appropriate when death is clearly imminent and inevitable. Here a person may refuse forms of treatment which at best provide a precarious and burdensome prolonging of life. In these cases, the person would place himself in Gods hands and prepare to leave this life, while maintaining ordinary means of health care.

At this point, we can specifically address the issue of nutrition and hydration. Never forget that basic, ordinary care for one's health entails food and water. The Ethical and Religious Directives for Catholic Health Care Services asserts, "There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient" (#58). The U.S. Bishops' Pro-Life Committee echoed this point, and added, "Such measure must not be withdrawn in order to cause death, but they may be withdrawn if they offer no reasonable hope of sustaining life or pose excessive risks and burdens" (#6).

Interestingly, the Holy Father, at a meeting with a group of U.S. Catholic Bishops from California, Nevada, and Hawaii in Rome on October 2, 1998 affirmed this statement of the Pro-Life Committee. He said that the statement "rightly emphasizes that the omission of nutrition and hydration intended to cause a patient's death must be rejected and that, while giving careful consideration to all the factors involved, the presumption should be in favor of providing medically assisted nutrition and hydration to all patients who need them. To blur this distinction is to introduce a source of countless injustices and much additional anguish, affecting both those already suffering from ill health or the deterioration which comes with age, and their loved ones" (Catholic News Service, Oct. 5, 1998). Interestingly, the Oct. 2 meeting was the same day the tubes providing food and water for Hugh Finn were removed.

Therefore, nutrition and hydration (food and water) are considered normal, basic, ordinary care. Moreover, nutrition and hydration provided through IVs or gastric tubes do not generally cause grave discomfort; serious, lasting side effects; or costly financial burdens. (Please note that if a serious medical condition did arise from the means of providing nutrition and hydration, the proportion of benefit would have to be considered against the burden.) Generally, providing a patient with nutrition and hydration may cease only when a person is imminently dying and such care is really useless, or when the person can no longer assimilate the nutrition and hydration. (Confer William May, et. al., Feeding and Hydrating the Permanently Unconscious and Other Vulnerable Persons, 1987).

A truly vulnerable person in this matter is the one in a persistent vegetative state (PVS). Note that we must be careful not to confuse PVS with brain death. PVS is deeper than a coma; it is a form of deep unconsciousness. Here the cerebrum is impaired and therefore many of the regular activities of a person cease. However, the brain stem is still functioning, and this portion of the brain controls involuntary functions such as breathing, blinking, involuntary contractions, and cycles of waking and sleep. A PVS patient may also have a near-normal EEG. Keep in mind that the diagnosis of "brain death" is based on the "total and irreversible cessation of all brain function, including the brain stem" (cited in the Cruzon case). A PVS patient is therefore alive. Granted, the likelihood of his recovery is slim. Nevertheless, to remove nutrition and hydration must not be with the intention to kill the patient. (Confer Pennsylvania Catholic Bishops, Nutrition and Hydration: Moral Considerations, pp. 7-8.)

Finally, the last moral point to remember is our Christian perspective of suffering. No one enjoys suffering. However, we must remember that each of us was baptized into Christ's passion, death, and resurrection. We all share in our Lord's cross, and that at times may be very painful. This suffering, however, especially at the last moments of one's life, must be seen as a sharing in our Lord's sufferings. By uniting our suffering with our Lord's, we expiate the hurt caused by our own sins and help to expiate the sins of others, just as some of the early martyrs did who offered their sufferings for sinners. Sometimes, such suffering finally heals the wounds that have divided families. In all, we must look to Christ to aid us in our suffering and guide us from this life to Himself.

In all of these principles, the Church strives to uphold the sanctity of human life as well as provide clear moral guidance in an age where medical technology for all of its goodness has complicated dying. We must never forget that there is a great difference between purposely killing someone and allowing a dying person to die peacefully with dignity. We must remember that "what a sick person needs, besides medical care, is love, the human and supernatural warmth with which the sick person can and ought to be surrounded by all those close to him or her, parents and children, doctors and nurses" (Declaration on Euthanasia). Sharing in the sufferings of our loved ones and helping them to prepare to return to our Lord is indeed a great act of love.