BY: FR. KEVIN O'ROURKE, OP, JCD, STM
Fr. O'Rourke is professor of bioethics, Stritch School of Medicine, Loyola
University, Chicago.
In the past 15 years, American bishops—acting at times alone, at other times
in state conferences, or as members of a committee of the U.S. Conference of
Catholic Bishops—have issued more than 15 pastoral statements concerning the
care of people approaching death.
Some of these statements were written in regard to specific people. For example,
local bishops made statements regarding the care of Paul Brophy, Elizabeth Bouvia,
Nancy Beth Cruzan, Christine Busalacchi, and Hugh Finn. In most cases, these
statements acknowledged the anguish and suffering of those family members who
had to make decisions about removing life support, and the bishops usually agreed
that the family involved was not trying to kill its loved one but merely seeking
to discontinue useless treatment or to remove an excessive burden.
Other statements have been issued by state Catholic conferences—for example,
the conferences of Louisiana, Pennsylvania, New Jersey, and Washington—and by
several bishops from the state conference of Texas and the Pro-Life Committee
of the National Conference of Catholic Bishops.
All statements of this latter kind have been general in nature,
considering issues from a more didactic point of view than did
those issued for specific clinical cases. Often these statements
seemed more concerned with combating the growing evil of euthanasia
in the United States than with offering practical advice about
death and dying. However, they did not always agree on the use
of specific therapies. For example, some statements discouraged
the removal of artificial hydration and nutrition from patients
in persistent vegetative state (PVS). Others, basing themselves
on the traditional teaching of the church as contained in Directives
56, 57, and 58 of the Ethical and Religious Directives for
Catholic Health Care Services (ERD), have been inclined
to allow removal of these devices if they were of no benefit
to the patient or imposed an excessive burden upon the patient,
the family, or society.1
The bishops of Illinois have recently issued a statement,
entitled Facing the End of Life: A Pastoral Letter from the
Bishops of Illinois, in regard to the ethical decisions
that patients or their proxies must make.2 Is this
statement any better or worse than the aforementioned statements
of individual bishops or groups of bishops? Does it contain
new insights in regard to difficult medical and ethical decisions?
Will it be helpful to people who must decide whether to use
or forgo life-support devices designed to prolong life? For
example, will it be helpful to the patient who realizes that,
although an artificial heart might prolong his or her life another
six months, it will not improve the quality of life significantly?
The following considerations are intended to answer these questions.
Doctrinal Teaching
All of the U.S. bishops' general statements referred to above begin with doctrinal
considerations. Basing themselves on principles of faith, the bishops make it
clear that death is a natural and integral part of human life, not something
that we experience apart from life. More than anything else, preparing for and
experiencing death, whether it be one's own or that of a loved one, helps us
to realize what it means to be human. Moreover, the various statements of the
bishops integrate the many decisions that must be made as death approaches—whether
medical, familial, or economic—with the spiritual good of the patient. Thus
spirituality is not a separate aspect of dying; it is an integrating element
for everyone involved in the dying process of one of God's children.
Given these general ideas, each of the bishops' statements has its own identity.
The Illinois bishops' statement is characterized by brevity. It is brief enough
and clear enough to be understood by people facing death, by their families,
and by the health care professionals providing the care. Most of the statements
written by state Catholic conferences are simply too long and too opaque, so
far as the general public is concerned. Often such statements were written by
theologians for theologians, employing theological terms in a manner that neither
laity nor health care professionals can grasp easily. The Illinois bishops'
document is only six and one-half pages long. After presenting some foundational
teaching that enables the reader to "consider death in the context of our faith,"
it highlights what it calls "three crucial issues":
- The role of medical care at the end of life
- The proper understanding of suffering and the value of suffering
- The difficulty Americans have with the loss of independence and control
In "considering death in the context of our faith," the pastoral letter focuses
on the purpose of human life. "The value of human life is truly found in our
supernatural destiny and a recognition that death is not the end," the bishops
write. "Preparation for death is an essential part of life for a Christian.
. . . The key to dying well is living well. Living well means a life characterized
by love of God and love of neighbor. . . . Recognizing that the goal of our
lives is eternal life with God, we prepare for that by prayer, reception of
the sacraments and care for those around us, especially the poor and the forgotten"
(p. 107). In carrying on the tradition of treating death as a part of life,
the Illinois bishops call on the Catholic community to help build "a civilization
of love amid our current American culture of death" (p. 109).
After outlining the "context of faith" within which decisions at the end of
life should be made, the pastoral letter discusses the role of medical care
in the dying process. Two extremes should be avoided. "The first is an attitude
that one can end life, either by an action, like a lethal injection . . . or
by deliberately withholding therapy with the goal of bringing about a person's
death" (p. 107). Clearly, withholding therapy with the goal of bringing about
a patient's death is a much different moral action than withholding therapy
with the goal of ending futile or excessively burdensome therapy. The second
extreme to be avoided is vitalism: "the erroneous belief that our life
on earth has absolute value and all means must be taken for its preservation"
(p. 107).
Advice to Health Care Professionals
To avoid these two extremes, the bishops, although not extending "a definitive
pronouncement on every clinical decision (p. 107)," do offer some specific
norms for physicians to apply when making clinical decisions.
Life-Sustaining Therapies "Physicians should not impose aggressive
life-sustaining therapies on persons for whom such treatments will simply prolong
the dying process" (p. 108).
Patients' and Families' Wishes "Doctors do wrong who insist on maintaining
invasive life support when the patient or his or her family make clear that
the burdens of treatment far exceed the benefits" (p. 108).
Frankness about Death "A good Catholic doctor speaks openly about death
and dying with his or her patients, is frank about the limits of medical care,
works hard to prolong life and never deliberately takes life, but recognizes
that there are times when treatments should be withheld or withdrawn" (p. 108).
Pain control is also a prominent responsibility of physicians, and the pastoral
letter distinguishes between physical pain, on one hand, and suffering, on the
other. Suffering, the bishops write, "is part of the existential burden of knowing
that our time on earth is ending, facing the loss of relationships and the good
things of life, and dealing with the loss of independence and freedom that terminal
illness often brings" (p. 109). Suffering is salvific if joined to the suffering
of Christ, but this realization should not be transformed into a "glorification
of pain" (p. 109).
The bishops call attention to the compassion of nurses, which enables them
to help ease the patient's and the family's fears and make sure that control
of physical pain is a top priority in the medical and nursing plan (p. 108).
To my knowledge, this is the first document of its kind to emphasize the role
of nurses as patient advocates and to recognize explicitly that they are essential
members of the healing team at the time of death.
Advice to Patients and Families
The pastoral letter also offers sound ethical and medical advice to patients
and to those who will implement the wishes of patients unable to make decisions
for themselves. It declares, for example, that "there is no obligation to resort
to every type of therapy in an effort to preserve life regardless of the likelihood
of outcome. At the end of chronic illnesses like cancer or dementing illness,
the benefit of life-prolonging therapy is greatly limited." For those, moreover,
"who are suffering from metastatic cancer, end-stage congestive heart failure,
or advanced Alzheimer's disease or other forms of dementia, it is difficult
to see any justification for resuscitation in the event of cardiac arrest or
the prolonged use of intubation and mechanical ventilation" (p. 108).
In discussing the refusal or removal of artificial nutrition and hydration
for patients in conditions described above, the bishops refer to the more conservative
viewpoint of the Pro-Life Committee of the National Conference of Catholic Bishops,
but they also point out that using such therapy "in some cases at the end stage
of terminal disease like cancer might directly increase the suffering of the
patient and perhaps inadvertently hasten death" (pp. 108-109).
Overall, it seems that it would have been more effective to
simply consider artificial hydration and nutrition as "just
another" form of life-prolonging therapy and make decisions
in its regard in accord with Directives 56 and 57. Once again,
to my knowledge, this is the first document conveying church
teaching regarding dying patients to list advanced Alzheimer's
disease as a condition which might justify the withholding or
removal of life support, even artificial nutrition and hydration.
This conclusion fits the context of the purpose of life described
at the beginning of the pastoral letter (p. 107). Unless able
to perform human acts, a person cannot pursue the purpose of
life; the symptoms associated with advanced Alzheimer's disease,
for example, demonstrate that the person suffering from it cannot
perform human acts, that is, acts of the intellect and will.3
Recent articles in leading medical journals have, moreover,
affirmed the fact that artificial hydration and nutrition are
often not beneficial for dying patients.4
Omitted Distinctions
Finally, it is worth remarking that two distinctions included by some bishops
in their statements on death and dying are omitted from the Illinois bishops'
pastoral letter.
"Normal Care" Versus "Medical Therapy" The first is the distinction
between "normal care" and "medical therapy." Normal care might be termed "comfort
care," and some bishops and their theologians have used the distinction between
it and medical therapy to justify continuing the administration of food and
water to patients in PVS.
But research indicates that artificial administration of food and water offers
neither comfort to the person in PVS nor hope that it can restore his or her
impaired human function, even though it may prolong mere physiological function.
Insofar as "comfort care" includes keeping the patient clean and comfortable,
the distinction may be justified. But the fact that physicians, nurses, and
many medical ethicists with clinical experience consider administering food
and water to the body of a PVS to be a medical therapy—not comfort care—has
not been acknowledged in the pastoral statements issued by the bishops and theologians
who propound the distinction. Thus the distinction does not seem to be valid
in so far as ethical decisions at the time of death are concerned.
"Imminent and Inevitable Death" The Catholic Church
has traditionally maintained that life support may be withdrawn
if it is not beneficial for the patient or it imposes an excessive
burden on the patient or his or her family or community. Thus
this teaching has not implied that the patient must be in the
throes of death before he or she (or a proxy) decides that life
support is not beneficial. In the past few years, however, some
statements coming from authoritative sources—the encyclical
Evangelium Vitae (n. 65), for example—have suggested
that life support may not be removed unless "death is imminent
and inevitable." Of course, life support may be removed if death
is imminent and inevitable, but must a pathology be so far advanced
before life support is withheld or removed? Is it not ethically
acceptable to remove or reject life support if it is determined
to be ineffective or an excessive burden before death
is "imminent and inevitable"? Over the centuries, moral theologians
have offered examples of people who need not accept exotic or
burdensome forms of life support even though death was not "imminent
and inevitable." Thus following an expensive or exotic diet,
even if it would prolong life, was not deemed morally necessary.
Moreover, moral theologians maintained that a person would not
have to move to a better climate, or change his or her manner
of making a living, in order to prolong his or her life. The
norms set forth in Directives 56 and 57 do not say that death
must be imminent and inevitable before life support can be rejected
or removed. If taken literally, saying that death must be "imminent
and inevitable" before life support is withheld or removed would
not seem to be an accurate statement of Catholic tradition.
As Francis de Vittoria, the pioneer in death and dying theology
stated in the 16th century, "It is one thing to shorten life
and another thing not to prolong it."5
A Step Forward
In sum, the Illinois bishops' pastoral letter is a step forward because it
presents church teaching in a succinct and understandable manner. Its enlightened
tone may be owing to the fact that a practicing physician contributed to it,
along with theologians and bishops. This collaboration has produced a patient-
and family-centered document for physicians, other health care professionals,
and patients and their families. "In consulting with legitimate church teaching,
our consciences can be formed so that decisions made even in emotionally laden
situations are moral, compassionate and appropriate" (p. 109).
Copies of Facing the End of Life: A Pastoral Letter
from the Bishops of Illinois may be had by calling the Illinois
Catholic Health Association at 312-368-0011.
NOTES
- U.S. Conference of Catholic Bishops, Ethical and Religious Directives
for Catholic Health Services, 4th ed., Washington, DC, 2001, p. 31.
- Illinois Bishops, "Facing the End of Life," Origins, June 21, 2001,
pp. 105, 107-109.
- Thomas Aquinas, Summa Theologica, I-II, q. 1. a. 1., Benziger Brothers,
New York City, 1947.
- A. Finucane, "Tube Feeding in Patients with Advanced Dementia," JAMA,
October 13, 1999, pp. 282-294; B. Gillick, "Rethinking the Role of Tube Feeding
in Patients with Advanced Dementia," New England Journal of Medicine,
January 20, 2000, pp. 342-346.
- Francis de Vittoria, On Homicide, J. P. Doyle, ed., Marquette University
Press, Milwaukee, 1997, p. 103.
Copyright © 2002 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.