Death and Dying

What is the Church saying aboutUsing or forgoing life-sustaining treatments (LST)

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DistinctionsForgoing life-sustaining treatment (withholding or withdrawing treatment) versus Euthanasia and assisted suicide

2Theology of Death and DyingCatholic Health Association:In the Roman Catholic tradition, human life is regarded as sacred from the moment of conception until natural death because it is created and given to us by God. For this reason, we have a duty to protect and preserve our lives. Yet this duty is not absolutely binding under all circumstances because we know that our ultimate end lies in eternal life with God. (italics added)

Theology of Death and DyingPope John Paul II in Evangelium Vitae observes that it is precisely this supernatural calling which highlights the relative character of each individuals earthly life. After all, life on earth is not an ultimate but a penultimate reality.

In light of this belief, it has been widely accepted among Catholic moralists from the 16th century onward that one need only employ ordinary means of preserving life, but not those deemed extraordinary

Principles for making decisions about LST in the Catholic Tradition: HistoricalOrdinary/extraordinary treatment distinction

Principle: Ordinary treatments should be used but permissible to forgo treatments which are extraordinary in character

Problems with distinction and principle

5Principles for making decisions about LSTRefinement in Declaration on Euthanasia (1980): proportionate and disproportionate means

Proportionate/disproportionate means understood in terms of benefits and burdens

6Principles for making decisions about LST: Benefits/BurdensEthical and Religious Directives for Catholic Health Care Services (ERD)

56. A person has a moral obligation to use ordinary or proportionate means of preserving his or her life. continued

7Principles for Making Decisions about LST: Benefits/BurdensERD no. 56Proportionate means are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community.

8Principles for Making Decisions about LST: Benefits & BurdensERD no. 57 A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patients judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.

9Benefits and Burdens PrincipleOrdinary treatment = proportionate to results = reasonable hope of benefit and no excessive burden

Extraordinary treatment = disproportionate to results = no reasonable hope of benefit or excessive burden

Benefits and Burdens PrincipleWhat are benefits? Some examples:Treatment will bring about a cure or at least improve the patients health statusTreatment will relieve painTreatment will increase the patients mobility Treatment will restore consciousnessTreatment will improve patients ability to communicate with others

Benefits and Burdens Principle What are burdens? Some examples:Treatment causes pain or substantial discomfortTreatment entails psychological burdens, e.g., depressionDifficulty getting access to treatment (e.g., driving distance)Patient has to be restrained to tolerate the treatmentSubstantial cost for patient and/or family

Benefits and Burdens PrincipleMorally permissible to forgo (withhold or withdraw) a life-sustaining treatment whenNo real hope of benefit to the patient (useless, futile)OR Excessively burdensome (the burdens of the treatment outweigh its benefits)

Who judges benefits and burdens: the patient (or his/her proxy decision maker)

13Benefits and Burdens PrincipleIn practice at bedside, has replaced the ordinary/extraordinary distinction

Difference from ordinary/extraordinary treatment distinction * No treatment automatically used/forgone * Decisions made on a case-by-case basis

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ClarificationsWithholding vs. withdrawing treatmentsEthically and legally, just as permissible to withdraw a treatment as never to start it

If unsure if a treatment will benefit a patient, a time-trial is recommended.

15Principles for Surrogate/Proxy Decision MakingPrinciple of Substituted Judgment (Gold standard): proxy attempts to reach decision that incapacitated patient would make, based on:Patients written or oral directivesKnowledge of patients beliefs, values, preferences, life-long behavior patterns

How would the patient judge the benefits and burdens of treatment?

16Principles for Proxy decision makingBest Interests Standard: proxy makes decision seeking to implement what is in patients best interests by reference to objective, societally shared criteria

Choosing as a reasonable person in the patients circumstances would choose

How would a reasonable person judge the benefits and burdens in this case?