End of Life End of Life issuesissues

Fr James McTavish, FMVDFr James McTavish, FMVD

Themes coveredThemes covered

OverviewOverview EuthanasiaEuthanasia Use of painkillersUse of painkillers Ordinary and extraordinary / Ordinary and extraordinary /

proportionate and disproportionate proportionate and disproportionate meansmeans

Artificial nutrition and hydration Artificial nutrition and hydration – – the case of Terry Schiavothe case of Terry Schiavo

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Importance of formation!Importance of formation!

Comedian Ali G confusing Comedian Ali G confusing “Euthanasia” with the “Youth in “Euthanasia” with the “Youth in

Asia”Asia” http://www.youtube.com/watch?v=Ya_uJHdOtdc&feature=related

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Etymology of wordEtymology of word

• EuthanasiaEuthanasia

• From the greek From the greek

eueu = = good good

thanatos thanatos == deathdeath

We want a good death! What does it We want a good death! What does it mean? mean?

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Euthanasia Euthanasia movementmovement

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“The good Lord gave me a position that obliged me to call what was black, black,

and what was white, white”

March 1946

Cardinal von GalenCardinal von Galen The Lion of Munster The Lion of Munster 3 famous homilies in 1941 3 famous homilies in 1941

““Here we are dealing with human beings, Here we are dealing with human beings, with our neighbours, brothers and sisters, the poor with our neighbours, brothers and sisters, the poor and invalids . . . unproductive—perhaps! But have and invalids . . . unproductive—perhaps! But have they, therefore, lost the right to live? Have you or I they, therefore, lost the right to live? Have you or I the right to exist only because we are ‘productive’? the right to exist only because we are ‘productive’? …Once we admit the right to kill unproductive …Once we admit the right to kill unproductive persons . . . then none of us can be sure of his life. persons . . . then none of us can be sure of his life. We shall be at the mercy of any committee that We shall be at the mercy of any committee that can put a man on the list of can put a man on the list of unproductives” unproductives”

(Excerpt from 3(Excerpt from 3rdrd homily, 3 homily, 3 Aug 1941)Aug 1941)

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Could such things happen Could such things happen today?today?

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The Groningen ProtocolEuthanasia in Severely Ill Newborns, 2005

Eduard Verhagen, M.D. and Pieter J.J. Sauer, M.D., Ph.D.

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BBC news July 2009BBC news July 2009Conductor dies in suicide Conductor dies in suicide

centre centre

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Renowned British conductor Sir Edward Thomas Downes, CBE, has died at the age of 85, after travelling to the assisted suicide centre Dignitas with his wife. He and his 74-year-old wife Joan, who was terminally ill, chose to end their lives at the Swiss centre, their family said in a statement. According to the statement, the couple "died peacefully, and under circumstances of their own choosing".

BBC news todayBBC news today

German doctor tried for German doctor tried for 13 deaths 13 deaths A German doctor has pleaded not A German doctor has pleaded not guilty to the manslaughter of 13 guilty to the manslaughter of 13 cancer patients who died from cancer patients who died from suspected overdoses of pain-suspected overdoses of pain-killing drugs.killing drugs.

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Today this proclamation is especially Today this proclamation is especially pressing because of the extraordinary pressing because of the extraordinary increase and gravity of threats to the increase and gravity of threats to the life of individuals and peoples, life of individuals and peoples, especially where life is weak and especially where life is weak and defenceless. defenceless. PJP II, Evangelium vitae 3PJP II, Evangelium vitae 3

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The need to announce the Gospel of Life in the world of

today

Definition of EuthanasiaDefinition of Euthanasia

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““An act or omission which of itself An act or omission which of itself or by intention causes death, in or by intention causes death, in order that all suffering may in order that all suffering may in

this way be eliminated”this way be eliminated” The Church’s Declaration on Euthanasia, 1980The Church’s Declaration on Euthanasia, 1980

Euthanasia can be performed by act or Euthanasia can be performed by act or omission. omission.

‘‘Active’ euthanasiaActive’ euthanasia

Active (direct, positive) euthanasia – Active (direct, positive) euthanasia – When death results from a positive action When death results from a positive action eg giving a lethal injection to a sick eg giving a lethal injection to a sick patient.patient.

Direct euthanasia consists in putting an end to the lives of Direct euthanasia consists in putting an end to the lives of handicapped, sick or dying persons. Thus an act or omission which, handicapped, sick or dying persons. Thus an act or omission which, of itself or by intention, causes death in order to eliminate suffering of itself or by intention, causes death in order to eliminate suffering constitutes a murder gravely contrary to the dignity of the human constitutes a murder gravely contrary to the dignity of the human and person and the respect due to the living god, his Creator. The and person and the respect due to the living god, his Creator. The error of judgment into which one can fall in good faith does not error of judgment into which one can fall in good faith does not change the nature of this murderous act, which must always be change the nature of this murderous act, which must always be forbidden and excluded. forbidden and excluded. (CCC 2277) (CCC 2277)

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‘‘Passive’ euthanasiaPassive’ euthanasia

Passive (indirect, negative) Passive (indirect, negative) euthanasia euthanasia – Omission of life saving – Omission of life saving medical care with the intention and result medical care with the intention and result of causing the patients deathof causing the patients death

  Discontinuing medical procedures that are burdensome, dangerous, Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of “over-zealous” treatment. Here one 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 does not will to cause death; one’s inability to impede it is merely accepted. The decision should be made by the patient if he is accepted. The decision should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always patient, whose reasonable will and legitimate interests must always be respected. be respected. (CCC 2278)(CCC 2278)

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Can painkilling drugs be used Can painkilling drugs be used even if life may be even if life may be

shortened ?shortened ? Morphine used to relieve painMorphine used to relieve pain It will slow down rate of breathing and may It will slow down rate of breathing and may

shorten lifeshorten life

““The use of painkillers to alleviate the The use of painkillers to alleviate the sufferings of the dying, even at the risk of sufferings of the dying, even at the risk of shortening their days, can be morally in shortening their days, can be morally in conformity with human dignity if death is not conformity with human dignity if death is not willed as either an end or a means, but only willed as either an end or a means, but only foreseen and tolerated as inevitable.”foreseen and tolerated as inevitable.”(CCC 2279) (CCC 2279)

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How to decide in real life situations How to decide in real life situations if the withholding of treatment is if the withholding of treatment is correct or not?correct or not?

We should not under treat but We should not under treat but neither should we undertake over-neither should we undertake over-zealous or futile treatmentzealous or futile treatment

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Are there any guiding Are there any guiding principles in the Church principles in the Church

teaching that can help us?teaching that can help us?

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1616thth century … century …

Domingo Bañez OP (1595)Domingo Bañez OP (1595)

Although a man is held to conserve his own Although a man is held to conserve his own life, he is not bound to extraordinary means life, he is not bound to extraordinary means but to common food and clothing, to common but to common food and clothing, to common medicines, to a certain common and ordinary medicines, to a certain common and ordinary pain; not, however, to a certain extraordinary pain; not, however, to a certain extraordinary and horrible pain, not to expenses which are and horrible pain, not to expenses which are extraordinary in proportion to the status of extraordinary in proportion to the status of this man. Although that means (amputation) this man. Although that means (amputation) is proportioned according to right reason and is proportioned according to right reason and from the consequence is licit, it is however, from the consequence is licit, it is however, extraordinary.”extraordinary.”

““Ordinary Ordinary means of preserving life are means of preserving life are all medicines, treatments and all medicines, treatments and operations which offer a operations which offer a reasonable reasonable hope of benefit hope of benefit for the patient and for the patient and which can be obtained and used which can be obtained and used without excessive without excessive expenseexpense, , painpain or or other other inconvenienceinconvenience.”.”

See Gerard Kelly, “The Duty to Preserve Life”, Theological Studies 12 See Gerard Kelly, “The Duty to Preserve Life”, Theological Studies 12 (1951) 550.(1951) 550.

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““Extraordinary Extraordinary means of means of preserving life are those treatments, preserving life are those treatments, medicines and operations which are medicines and operations which are gravely burdensomegravely burdensome to the patient, to the patient, and which cannot be obtained or and which cannot be obtained or used without excessive used without excessive expenseexpense, , painpain or other or other inconvenienceinconvenience or which, if or which, if used, used, would not offer a reasonable would not offer a reasonable hope of benefit hope of benefit to the patient.”to the patient.”

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Proportionate Proportionate meansmeans is any treatment that, is any treatment that, in the given circumstancesin the given circumstances, offers , offers a a reasonable hope of benefit reasonable hope of benefit andand is is not too burdensomenot too burdensome for the patient for the patient or others. or others.

Principle of Proportionate and Principle of Proportionate and Disproportionate MeansDisproportionate Means

Often used synonymously with the Often used synonymously with the term "ordinary/extraordinary means" term "ordinary/extraordinary means" since the two sets of terms were since the two sets of terms were equated in the 1980 Vatican equated in the 1980 Vatican Declaration on EuthanasiaDeclaration on Euthanasia. .

DISTINCTIONSDISTINCTIONS

Ordinary = Ordinary = obligatoryobligatoryOrdinary Ordinary does notdoes not = = usual usual

Extraordinary = Extraordinary = optionaloptionalExtraordinary Extraordinary does notdoes not = = unusual unusual

As conceived in the Catholic moral As conceived in the Catholic moral tradition, the principle holds that tradition, the principle holds that one one is obligated to preserve his or her is obligated to preserve his or her own life by making use of ordinary own life by making use of ordinary means, but is under no obligation to means, but is under no obligation to use extraordinary means.use extraordinary means.

(see (see Ethical and Religious DirectivesEthical and Religious Directives, nn. , nn. 32, 56 and 57)32, 56 and 57)

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Ordinary or Ordinary or extraordinary?extraordinary?

““It will be possible to make a correct It will be possible to make a correct judgment as to the means by studying judgment as to the means by studying the type of treatment to be used, its the type of treatment to be used, its degree of complexity or risk, its cost and degree of complexity or risk, its cost and the possibilities of using it, and the possibilities of using it, and comparing these elements with the comparing these elements with the result that can be expected, taking into result that can be expected, taking into account the state of the sick person and account the state of the sick person and his or her physical and moral resources”his or her physical and moral resources”

(See Part IV, Due Proportion in Use of Remedies, (See Part IV, Due Proportion in Use of Remedies, The Church’s Declaration on Euthanasia, 1980)The Church’s Declaration on Euthanasia, 1980)

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Ordinary or Ordinary or extraordinary?extraordinary?

Classification is relative to the state of Classification is relative to the state of medical progressmedical progress eg blood transfusions were extraordinary in the 1930’s but eg blood transfusions were extraordinary in the 1930’s but now may be an ordinary means of treatment. now may be an ordinary means of treatment.

It is relative to the It is relative to the local medical facilitieslocal medical facilities available – available – what is ordinary in the USA eg chemotherapy may be what is ordinary in the USA eg chemotherapy may be extraordinary in Africa. extraordinary in Africa.

Financial considerationsFinancial considerations may apply eg weekly kidney may apply eg weekly kidney dialysis at P7000 per week may be ordinary for one family, dialysis at P7000 per week may be ordinary for one family, but extraordinary for another. How much should the family but extraordinary for another. How much should the family reasonably do to get the money? reasonably do to get the money?

Pains Pains and and burdensburdens are not the same for each person. are not the same for each person.

The same treatment many offer one patient The same treatment many offer one patient hope of cure hope of cure but not anotherbut not another

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Importance of distinction Importance of distinction between ordinary and between ordinary and extraordinary meansextraordinary means

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The case of Terry The case of Terry SchiavoSchiavo

StoryStory

26 y.o. American womanCardiac arrest with anoxic brain damageEntered PVS15 yearsFed with PEG tube

Food and water, Food and water, ordinary or ordinary or extraordinary extraordinary treatment? treatment?

Husband received moneyHusband received money Had another relationshipHad another relationship Wanted to remove tube but Wanted to remove tube but

parents denied thisparents denied this

Pope John Paul IIPope John Paul II“…“…the administration of water and the administration of water and food, even when provided by artificial food, even when provided by artificial means, always represents a means, always represents a natural natural means means of preserving life, not a of preserving life, not a medical medical act.act. Its use, furthermore, should be Its use, furthermore, should be considered, in principle, considered, in principle, ordinary ordinary and and proportionateproportionate, and as such morally , and as such morally obligatory, insofar as and until it is seen obligatory, insofar as and until it is seen to have attained its proper finality, to have attained its proper finality, which in the present case consists in which in the present case consists in providing nourishment to the patient providing nourishment to the patient and alleviation of his suffering.”and alleviation of his suffering.”

ADDRESS OF JOHN PAUL II TO THE PARTICIPANTS IN THE ADDRESS OF JOHN PAUL II TO THE PARTICIPANTS IN THE INTERNATIONAL CONGRESS ON "LIFE-SUSTAINING INTERNATIONAL CONGRESS ON "LIFE-SUSTAINING TREATMENTS AND VEGETATIVE STATE: SCIENTIFIC ADVANCES TREATMENTS AND VEGETATIVE STATE: SCIENTIFIC ADVANCES AND ETHICAL DILEMMAS" AND ETHICAL DILEMMAS"

Saturday, 20 March Saturday, 20 March 20042004

See video clip (from 42 seconds See video clip (from 42 seconds onwards)onwards)

http://www.youtube.com/watch?v=Z9Ff-JSv6rM

The outcome…The outcome…

The American justice system The American justice system decided to remove her PEG decided to remove her PEG feeding tube and she died of feeding tube and she died of

dehydration on March 31, 2005.dehydration on March 31, 2005.

CDF and AN&H CDF and AN&H (2007)(2007)

First question:First question: Is the administration of food and water Is the administration of food and water (whether by natural or artificial means) to a patient in a (whether by natural or artificial means) to a patient in a “vegetative state” morally obligatory except when they “vegetative state” morally obligatory except when they cannot be assimilated by the patient’s body or cannot be cannot be assimilated by the patient’s body or cannot be administered to the patient without causing significant administered to the patient without causing significant physical discomfort?physical discomfort?

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

CDF and AN&H CDF and AN&H (2007)(2007)

Second question:Second question: When nutrition and hydration are When nutrition and hydration are being supplied by artificial means to a patient in a being supplied by artificial means to a patient in a “permanent vegetative state”, may they be “permanent vegetative state”, may they be discontinued when competent physicians judge with discontinued when competent physicians judge with moral certainty that the patient will never recover moral certainty that the patient will never recover consciousness?consciousness?

Response: Response: No. A patient in a “permanent vegetative No. A patient in a “permanent vegetative state” is a person with fundamental human dignity state” is a person with fundamental human dignity and must, therefore, receive ordinary and and must, therefore, receive ordinary and proportionate care which includes, in principle, the proportionate care which includes, in principle, the administration of water and food even by artificial administration of water and food even by artificial means.means.

Concluding…Concluding…

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Saint Gregory of NyssaSaint Gregory of Nyssa

"Man, as a being, is of no account; he is dust, "Man, as a being, is of no account; he is dust, grass, vanity. But once he is adopted by the God grass, vanity. But once he is adopted by the God of the universe as a son, he becomes part of the of the universe as a son, he becomes part of the family of that Being, whose excellence and family of that Being, whose excellence and greatness no one can see, hear or understand. greatness no one can see, hear or understand. What words, thoughts or flight of the spirit can What words, thoughts or flight of the spirit can praise the superabundance of this grace? Man praise the superabundance of this grace? Man surpasses his nature: mortal, he becomes surpasses his nature: mortal, he becomes immortal; perishable, he becomes imperishable; immortal; perishable, he becomes imperishable; fleeting, he becomes eternal; human, he fleeting, he becomes eternal; human, he becomes divine". becomes divine". See EV 80 See EV 80 ((From From De BeatitudinibusDe Beatitudinibus, , Oratio VII: Oratio VII: PGPG 44, 1280 44, 1280))

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2 Timothy 4:2-5 2 Timothy 4:2-5

Proclaim the word; be persistent whether it Proclaim the word; be persistent whether it is convenient or inconvenient; convince, is convenient or inconvenient; convince, reprimand, encourage through all patience reprimand, encourage through all patience and teaching. For the time will come when and teaching. For the time will come when people will not tolerate sound doctrine but, people will not tolerate sound doctrine but, following their own desires and insatiable following their own desires and insatiable curiosity, will accumulate teachers and will curiosity, will accumulate teachers and will stop listening to the truth and will be stop listening to the truth and will be diverted to myths. But you, be self-possessed diverted to myths. But you, be self-possessed in all circumstances; put up with hardship; in all circumstances; put up with hardship; perform the work of an evangelist; fulfill perform the work of an evangelist; fulfill your ministry. your ministry.

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