End-of-Life Health Care Decisions are Difficult
Supplement to the St. Louis Review (Archdiocesan newspaper), October 3. 2003

By Father Edward J. Richard, MS

Decisions affecting treatment and care at the end of a person's life can present extraordinary difficulties for those involved.

The public recognition of issues about treatment and care at the end of life has made almost everyone aware, if not fearful, of the possibility of becoming dependent upon other people and technological help to sustain one's life when a life-threatening condition befalls oneself or a loved one. The impending sense of loss can become entwined with other emotions surrounding serious questions about appropriate care of the seriously ill or dying person. Since many families do not discuss these matters beforehand, decisions often have to be made when the result is a matter of life and death. There are many questions that could be clarified beforehand by a loving and frank discussion within the family.

Many people make statements about not wanting to be "put on a tube" or "hooked up to a machine." They fear that their lives will be prolonged needlessly when there is no chance of getting better, an idea that has been planted in many minds by supporters of euthanasia. Other times people make these statements because they do not want to "be a burden" to the rest of their family or to a particular relative who will have the most responsibility for their care.

How many people will make decisions to forgo treatment because they think the requirements of caring for them will be too much of an inconvenience upon their children or other close relatives? A little bit of concern and a desire to be of Christ-like service to those we are close to can make a difference in assuring that loved ones live and, when the time comes, die surrounded by love.

Hospitals and other health-related institutions are required to make inquiries of a person about future treatment decisions when that person is admitted. This is one way people become acquainted with the practical realities of what are called "advance directives" or "advance declarations" for health care. Usually, the hospital forms appear to be quite simple and straightforward since the person is asked just to mark the form beside each type of treatment that one would like to refuse. For example, the form typically provides the person with the opportunity to refuse, in advance, such things as cardio-pulmonary resuscitation, dialysis, ventilator, insulin and antibiotics, and even food and water when it is administered through a tube because the person becomes unable to swallow. No one is required to check anything off the form and can request all beneficial treatment.

The hospital is directed not to provide any kind of treatment the patient marks off, usually without regard to the moral circumstances that are involved in the case. Failure to provide any of these can and usually will result in the patient's death. These are the same kinds of questions that are covered by the so-called "Living Will" and "Durable Power of Attorney for Health Care Decisions. "

In most cases, health care professionals will try diligently to conform to the wishes of the patient or the person who is making decisions for the patient. However, in some family cases, members disagree among themselves or with hospitals over the level of care to be given. Some of the more troubling cases end up being decided by courts. Often these situations can be avoided by discussions with one's family and physician. At the same time, though, consumers of medical services should be aware that more health care providers are willing to disagree with patients or their family members, especially when the physician and hospital agree that a treatment should not be given even if the family would like it. More hospitals are adopting policies known as "medical futility" policies to give them the legal right to refuse treatment to a patient because they do not think the patient will benefit from it. This can be based on the judgment of medical personnel that the patient's quality of life will not be sufficient after the treatment to merit prolonging the life of the patient.

Guidelines provided in the authentic teaching of the Church are helpful in these decisions whether or not the patient has an advance directive. These guidelines come from teachings by the Pope, a Vatican congregation, bishops and committees of the bishops' conference.

• Euthanasia is an action or omission, which by its nature or by intention causes death so that all suffering may be eliminated (Declaration on Euthanasia).

• Nothing and no one can in any way permit the killing of an innocent human being, whether a fetus or embryo, an infant or an adult, an old person, one suffering from an incurable disease or a person who is dying. Furthermore, no one is permitted to ask for this act of killing,either for himself or herself or for another person entrusted to his or her care, nor can he or she consent to it, either explicitly or implicitly.

• The moral responsibility of self-preservation obliges everyone to use the normal means that medicine can offer for preserving one's life.

• It is 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.

• 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 acceptingthem, the patient can show generosity in the service to humanity. It is also permitted with the patient's consent to interrupt these means where the results fall short of expectation.

• Discontinuing medical procedures that are burdensome, dangerous, extraordinary or disproportionate to the expected outcome can be legitimate; it is the refusal of "overzealous" treatment ("Catechism of the Catholic Church" 2278).

• 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.

• Even if death is thought imminent, the ordinary care owed to a sick person cannot legitimately be interrupted.

“A great teaching effort is needed to clarify the substantive moral difference between discontinuing medical procedures that may be burdensome, dangerous, or disproportionate to the expected outcome (overzealous treatment)... and taking away the ordinary means of preserving life, such as feeding, hydration and normal medical care.” (John Paul II, Oct. 2, 1998)

Persons who are faced with difficult medical care decisions should make a great effort to know and understand the patient's condition and to get whatever assistance one needs in doing so. When a difficult decision must be made and there is a lack of clarity about what prudence dictates in a case, one might choose to call the archdiocesan Pro-Life Office, (314) 792-7555.

Father Richard is a priest of the LaSalette Missionaries with doctorate degrees in law and moral theology. He is associate professor of moral theology and academic dean of Kenrick-Glennon Seminary in St. Louis and director of the Paul VI Pontifical Institute of Catechetical and Pastoral Studies.