To live and let die
To live and let die: some questions on the moral limits of medical treatment
By Fr. Juan Carlos Iscara
Whether we live, whether we die, we belong to the Lord. (Romans 14:8)
The inviolable laws of natural and Christian morality must be observed everywhere. It is not from emotive considerations nor from a materialistic natural philanthropy that the essential principles of medical ethics derive, but from these laws: the dignity of the human body, the preeminence of the soul over the body, the brotherhood of all men, the sovereign dominion of God over life and destiny. (Pope Pius XII)
Our duty to preserve life is at present one of the most important and most discussed moral problems — in fact, one of the central questions — in the relatively new field of "bioethics." The development of medical technologies — which now allow us to mechanically preserve the appearance of life in a body that, according to the medical science of the past, would have been considered a corpse — forces us once again to ponder over the notions of life and death, and to reformulate their moral consequences in the light of Catholic doctrine.
People who have their relatives or friends in the hospital connected to machines, and also their doctors and their priests, have to face the same problem and answer similar questions. Can or should treatment continue? Can the machines be disconnected? Is it a sin to disconnect them? Are we obliged to preserve life at all costs? Even when there is no hope of recovery? To what extent does the duty to preserve life — our own, the life of our loved ones, the life that has been entrusted to our care — bind us?
The Ethical Debate in America
The debate over these matters is particularly acute in the US, whose developments in the field of medical ethics are proposed as a model for the rest of the world. Unfortunately, these developments have suffered to different degrees the influence of some characteristics of American culture which proceed from non-Catholic roots.
According to the philosophy of the Enlightenment, which is at the base of American political doctrine,
...man has to be free, at least within the minimal limits which are compatible with public security, to follow and practice the faith in which he personally believes, in spite of its possible divergence regarding the prevailing ethics. The government has to protect his rights and it has specially to avoid the imposition of any religious value whatsoever on a society which is morally pluralistic.
In its most extreme forms, this doctrine exalts the values of personal freedom and autonomy above all others, making them the essential ethical values to be preserved at all costs: what preserves them is morally good and has to be done, what impedes them is morally evil and must be avoided.
Moreover, the basic tenets of Protestantism (even in its fundamentalist form, which would seem to be in opposition to these tendencies because of its insistence on an objective moral law dictated by God) favor the liberty of the individual in the interpretation of moral doctrine, bringing the conscience of the individual to a central position for the determination of what is morally permitted.
The economic philosophy of liberal capitalism adds to the present situation the tendency to consider the economy as more important than ethics. Physical health becomes one more among the material goods in the free market, and health care is consequently considered primarily as business, to the extent that today any agreement between doctors and hospitals on the reduction of health-care costs would be subject to legal penalties according to the "Sherman Anti-Trust Act," as if it were an attempt to set up a monopoly. The chronically ill, the incurable, and also the elderly, and the permanently handicapped risk being viewed as "bad investments" that have to be shunned.
American pragmatism, on its part, loves everything that works, is uneasy with speculative thought and abstract principles, and has doubts about, or plainly refuses, the existence of an objective and immutable moral order. This creates the tendency towards ethical utilitarianism: virtues might be exalted in political discourse, but when we get down to the level of practical realities, "ethical" is what works in a given situation.
Brought together, all these aspects of American life favor certain positions that have appeared in the last years in medical ethics: the tendency to withdraw food and drink, to consider as dead those who are partially "brain-dead," to use the tissues of aborted fetuses for experimentation, to attempt to put a price for the organs destined for transplants, to favor a position "pro-choice," even if one is opposed to abortion in itself, to have no consideration for those who argue from a theological point of view, and to favor the legalization of euthanasia and "assisted" suicide.
The legal precedents
The ethical problem, daunting by itself, is today compounded by the intervention of the law courts, which have replaced the Church as the ultimate authority for the exposition and clarification of ethical principles and for the setting down of the parameters to be followed in these matters. The court rulings in many controverted cases, apart from giving a "solution" to a concrete case, have become the legal precedents to be used for the next — albeit slightly different — case. So throughout the years the complex question of the duty to preserve life, and of the means for that end, has become a slippery slope down which we are slipping a bit farther every day.
The first major question came in the court case of 22-year-old Karen Ann Quinlan, comatose since 1975, when her family asked in 1976 for a court ruling allowing her mechanical respirator to be disconnected, in opposition to the physicians’ judgment, who considered that such an action would certainly cause her death in a matter of minutes. In a landmark decision, the New Jersey Supreme Court reversed a lower court decision and granted permission. The incident is important because it had consequences that go far beyond the particular case. The legal recourse both made the law court the ultimate arbiter in an ethical decision, with the actual power to enforce it, and created a general precedent applicable to all similar (but not necessarily identical) cases. By the way, this incident also shows us how uncertain is the certainty of some physicians, because after withdrawal of the respirator Karen Ann Quinlan continued breathing on her own, and died in 1985.
The next precedent-setting case was that of Nancy Beth Cruzan, a 32-year-old woman who had been in a persistent vegetative state since a car crash seven years earlier. The question was not of disconnecting the respirator, because she was breathing by herself, but to disconnect the artificial nutrition and hydration — food and water artificially administered. The Missouri Supreme Court did not grant this request, not because it considered it its ethical duty to preserve life, but because there was no "clear and convincing evidence" she had requested this to be done. In a second hearing of the case, new testimony was entered convincing the judge that Nancy never wanted "to live like a vegetable," and removal of the artificial nutrition was granted. She died 12 days later, December 26, 1990. A new legal — and ethical! — precedent was set down: the removal of artificial nutrition and hydration is permissible if the patient himself requests it.
The Cruzan case was the foundation of the next case along the slippery slope. A conscious and lucid patient, Murray Putzer, himself requested the withdrawal of the feeding tubes, which was granted because there was no doubt that he had requested it. In ten days, he died.
And now we have the Society for the Right to Die and Americans Against Human Suffering… The Hemlock Society has published a "do-it-yourself" manual for those who are "considering the option of rational suicide," while Dr. Kevorkian still goes around helping terminally ill and simply depressed people to end their lives…. The press and the courts talk about our "constitutional right" to die…
In a crazed world which is on the verge of the absolute loss of its moral bearings, the last rampart of moral sanity and of sound ethical judgment is the traditional Catholic doctrine.
The theological notions of ordinary and extraordinary means to preserve life
The answer to many of those questions relies upon the definition of ordinary and extraordinary means of preserving our own life. It is therefore necessary to start with these notions, their development and the changes which have ensued, particularly in modern times. Later, we shall investigate the application of these notions to the different medical technologies and set the Catholic guidelines for our judgment in these questions.
The doctrinal foundations
St. Thomas Aquinas set the initial parameters for the subsequent discussion about the question of the preservation of one’s life. Life is a gift from God. To take our own life is a sin, a violation of God’s dominion over life and death. The fifth Commandment, "Thou shalt not kill," is a negative precept, that is, it imposes the obligation not to do a certain action. In the context of our discussion, it means that we cannot kill ourselves. To this negative duty corresponds a positive duty, the obligation to do another action: we must preserve our life. To refuse this positive duty is equivalent to the violation of the negative precept, the Commandment of God:
A man has the obligation to sustain his body, otherwise he would be a killer of himself […]; by precept, therefore, he is bound to nourish his body and likewise we are bound to all the other items without which the body cannot live.
St. Thomas then asked if this is an absolutely binding obligation, and he answered; "Semper sed non pro semper," "always, but not in every circumstance." There are certain situations, certain conditions in which this positive duty does not bind, in which we can abandon the duty of preserving our own life for the attainment of the higher good — the service and attainment of God. The temporal good, that is, our life, must be sought if it helps us to attain our spiritual end, but it may be relinquished if it is an obstacle in our way towards God:
It is inbred for a man to love his own life and those things which contribute to it, but in due measure; that is, to love things of this kind not as though his goal were set in them, but inasmuch as they are to be used for his final end [the attainment of God, the salvation of his soul] 
In consequence, there is a binding obligation to preserve one’s life, but it is circumscribed by considerations related to the proper pursuit of our final end.
Having stated this, St. Thomas applied the principle of totality that Pius XII will recall again in this century. This principle considers the bodily integrity (wholeness) of man. Hence, a part of the body could be sacrificed for the good of the whole, and in this way, he concluded the lawfulness of mutilation: we can relinquish a part of our body to preserve our life.
In the 16th century Francisco de Vitoria, a Spanish Dominican, was the first to consider in greater detail the means to preserve our own life, without calling them as yet ordinary and extraordinary means. He stated that some means are obligatory, that is, that we are obliged to use them, and that to refuse their use when the need arises is equivalent to suicide, and consequently, a sin. Which are those? The means that are commonly used by men to preserve their own life and which are easily available to the vast majority of people: medicines, the recourse to a physician, food, water. The extraordinary means are, in consequence, those which are not common.
One is not held to employ all the means to conserve life, but it is sufficient to employ the means which are of themselves intended for this purpose and congruent.
But Vitoria added a consideration that was crucial for the development of moral doctrine: the judgment about the ordinariness of the means, if they are common or not, might, in certain particular cases, be relative to the condition of the person. Perhaps in a particular case, the means that are common and must be used by all — ordinary — might impose an excessive burden on a person. If it is morally impossible to use those means, even if they are common, even if they are the most easily available, a person may be exempted of their use without committing a sin. In other words: there might be circumstances in which, because of a subjective disposition, the ordinary means become extraordinary for a particular person; the excuse for not using them does not arise from the means themselves, but from the subjective moral impossibility of this concrete individual to use them.
Another Spanish Dominican, Domingo Banez, was the first to introduce the terms ordinary and extraordinary in the moral-theological discourse. Since then, the means that are commonly used are called ordinary, and their use is obligatory; those which are uncommon and from which use one can be excused, are called extraordinary.
Medical science had not advanced that much when Cardinal Juan de Lugo came back to the question, not to face new problems, but to propose a novel application of the axiom "moraliter pro nihilo reputatur": In the context of this discussion, it means that something, some means to preserve one’s life, is "morally considered as nothing." De Lugo himself gave an example: A man is high in a burning tower surrounded by flames; he cannot escape, but he finds that he has a bucket of water which he can throw to put out part of the fire and it will delay his death for some minutes. Is he obliged to use that water to try to put out the fire? No. Moraliter pro nihilo reputatur: such a small quantity will not affect the result, he will die no matter what. The distinction to be understood is that in this example the relief that is offered is so small that it amounts to nothing, and therefore, it does not create the moral obligation of using it.
The next theologian that we have in our listing is St. Alphonsus Liguori. He repeated everything that has been said before, but included another exception to obligatory action: the subjective repugnance of an individual to use a certain kind of medical treatment. He proposed the example of a virgin who, because of her delicacy of conscience and the real danger of temptation, refuses to be touched by a male physician.
Ordinary and Extraordinary Means
The means to be used are not defined, but described according to their ordinariness. A precise, universally applicable definition would have been an impediment for the practical judgment regarding the obligation in some concrete cases, due to particular and subjective circumstances. There is no definition, but a description of features which help us to judge if the means proposed are ordinary or extraordinary.
The distinction between ordinary and extraordinary means is used both by physicians and moral theologians, but such a use does not mean that their notions of "ordinary" and "extraordinary" are exactly the same. It may happen that the notions overlap, but they are not necessarily co-extensive: a means may be "ordinary" for the physician, in the sense of usual, standard medical practice, but considered "extraordinary" by the moral theologian, and conversely.
Ordinary means are those means which are commonly used by men to preserve their own life, and which can be procured by ordinary diligence. Four features have to be considered:
- Media communia, common means, what in the common judgment of men is necessary for the preservation of life: food, water, clothing, housing, medicines, the recourse to a physician. Their availability does not demand a diligence or solicitude that exceeds the usual care that most men normally give to their lives.
- Secundum proportionem status, the introduction of a certain subjective judgment in the means by comparison to one’s station in life. There are means that might be judged excessive for a common man, but which are not excessive for the president of the nation or for a distinguished scientist, not because of the absolute value of a human life, which is identical in each case, but simply because of the relative importance of that life for the common good.
- Medicina non difficilia, the medicines or means that are not difficult to obtain or use. For instance, the medicines that are easily found in any pharmacy, or the treatment available in every hospital, or the one that is considered standard medical practice. One has not to go to the other side of the world, to the only hospital which offers such treatment; one has not to subject oneself to a long and terribly painful treatment. In a word, it means that the medicines or treatment do not impose a great burden of expense, difficulty, inconvenience or pain.
- Spes salutis, the hope of a beneficial result:
- If the disease is so far advanced that no reasonable hope can be entertained of saving the patient’s life, he should not be molested, and the more doubtful the effect of a medicine or an operation…the less should he be harassed.
Regarding extraordinary means, we continue as before, without a definition, only with their objective description. Which are the features that distinguish these means?
- Quædam impossibilitas, not the physical impossibility of using them because of their unavailability, but the moral impossibility of using the available means. This includes any kind of impossibility that arises in the individual regarding the means of preservation of his own life — even the extreme subjective repugnance that St. Alphonsus was talking about.
- Summus labor, media nimis dura, the overwhelming and extremely difficult effort to use or to procure these means.
- Quidam cruciatus, ingens dolor. If the use of the means provokes such intense and constant pain that one cannot endure it, those means become extraordinary to that person, even if they are objectively ordinary.
- Sumptus extraordinarius, media pretiosa. This means that the expense is outrageous, to the extent of reducing the patient, or the person entrusted with his care, to poverty.
- Vehemens horror, an intense and overwhelming emotion of horror provoked by the use of those means.
The relations between objective quality, burden and benefit
We have tried to describe these means objectively, but nevertheless references to the subject, the individual, keep creeping in. This brings us to note some important points in this listing of means and features.
The first is that the emphasis has always to fall upon the objective quality of the means. The manuals of Moral Theology have made every effort to describe as objectively as possible which are ordinary and extraordinary means. This objective description establishes primarily a certain means as ordinary or extraordinary. Then, as a second stage, it comes the subjective application of those means to the patient, their actual use by a concrete individual.
The second point is that the notion of the burden imposed by the means has to be considered both objectively and subjectively. A certain means can be objectively burdensome, because of the difficulty to obtain it, its excessive cost, the severe pain that it inflicts. But it can also be subjectively perceived as burdensome:
In some particular circumstances a means, which is by itself ordinary, may be considered extraordinary because of a reasonable motive, and consequently not used.
The third point is that there is an inverse relationship of proportion between the objective ordinariness of the means and the subjective circumstances of their use. When the means are objectively ordinary, the subjective circumstances which would lead us to refuse their use have to be more grave and solidly founded. In a simpler proposition: the more ordinary the means are, the more extraordinary the subjective circumstances have to be to refuse their use without committing a sin.
The fourth point we must notice is the close relationship between the burden imposed by the use of the means and the beneficial result to be expected from such recourse. If the benefit is slight but the use of the means do not impose any burden, the obligation to use them remains. If the hope of a beneficial result is slight, but the means are objectively extraordinary, the obligation to use them is not urged.
The two lights which have to guide us for a right judgment in the particular case are:
- the objective quality of the means, and
- the proportional relation that must exist between burden, benefit and subjective circumstances.
The magisterium of Pius XII
Confronting the new medical technologies, and the ever more daring theories widely spread by too liberal theologians, many persons found themselves in doubt and asked the Church to present again her point of view on these questions. Pope Pius XII went back to sound tradition, to the basic principles of natural and Christian morals.
He reaffirmed the principle of totality. The good of man is the good of the whole person, not only his bodily integrity, but also the subordination of biological life to higher goods, the common good of civil and ecclesiastical society, the good of our own spiritual welfare:
[The patient] is bound by the immanent purposes fixed by nature.…Because he is the beneficiary, and not the proprietor, he does not possess unlimited power to allow acts of destruction or of mutilation of anatomic or functional character. But in virtue of the principle of totality, of his right to employ the services of the organism as a whole, he can give individual parts to destruction or mutilation when and to the extent that it is necessary for the good of his being as a whole, to assure its existence or to avoid, and naturally to repair, grave and lasting damage which could otherwise neither be avoided nor repaired.
What purpose would be served by the use and development of the body, of its energies, of its beauty, if it were not at the service of something more noble and lasting, namely, the soul?…It is sound to teach man to respect his body, but not to esteem the body more than is right.…Care of the body is not man’s first anxiety, neither the earthly and mortal body as it is now, not the glorified body made spiritual as it will be one day. The first place in man’s composite being does not belong to the body taken from the earth’s slime, but to the spirit, to the spiritual soul.
Pius XII also restated the notions of ordinary and extraordinary means. Ordinary are those treatments which offer reasonable hope of benefit without imposing unacceptable burdens on the patient or others, and they are considered always in relation to the different circumstances of persons, places, times and cultures. Extraordinary are those means which do impose unacceptable burdens. The pope did not address the specific criteria for distinguishing between ordinary and extraordinary treatments, but made only one specific application: the respirator for a dying patient can be considered as extraordinary means.
The "New Morals"
But great changes in Catholic moral theology were already brewing in the Forties. Fr. Gerald Kelly, an American Jesuit, set the new direction in the "definition" of ordinary and extraordinary means.
The first change was a shift in the focus of the definition. The descriptive definitions of the past — that is, the description of the features which distinguish the ordinary from the extraordinary means — were turned into a normative definition: ordinary means are those which are obligatory, extraordinary are those which are not obligatory. With this shift from the degree of difficulty to obtain or use the means, to a judgment about the obligation to use certain means, the whole question of the objective quality of the means was put aside: it does not matter how the means are, their objective nature, but only the obligation in reference to a concrete subject.
The second change was more important, the introduction — in the definition of ordinary and extraordinary means — of the explicit notion of the benefit for the patient, in such a way that "extraordinary means" came to include all medicines and treatments which cannot be obtained without excessive expense, pain, or other inconvenience, or which, if used, do not offer a reasonable hope of benefit. In the traditional doctrine, it was required a keeping of proportion between burden and benefit, and a continuous balance between both. In this new utilitarian definition, the notion of benefit is freed from the notion of burden, and they become two equal and independent parameters to judge about the obligation of the use of the means: the imposition of an excessive burden, or the lack of expectation of a beneficial result.
It may seem that we are splitting hairs and that there is no real difference between these definitions, the traditional and the new. But let’s look at the practical applications. A case discussed by Fr. Kelly regards a patient dying of cancer, who is also a diabetic and is taking insulin to avoid dying from a diabetic coma. Is he obliged to continue taking the medicine that keeps at bay one cause of death, while letting the other cause of death run its course? …According to traditional doctrine, we judge the objective ordinariness of the means and their relation to the end intended. In reference to the control of diabetes, insulin is the ordinary means, it is easily available and does not imply any excessive burden; therefore, the patient is obliged to continue taking it. On the contrary, according to the new notions of ordinary and extraordinary means, nothing will prevent the patient from dying: even if insulin is taken, he will die of cancer. As there is no real hope of benefit (the patient will nevertheless die), he is not obliged to take insulin.
A second case refers to the artificial feeding of a man who will die in the near future of a certain illness. While the artificial feeding prevents death from happening now, it will happen eventually, very soon. Is there a proportionate benefit? According to traditional doctrine, the benefit is certainly very slight, but so is the burden imposed; therefore, it constitutes ordinary means and has to be used. According to the new definition, "ordinary" and "extraordinary" are relative to the patient’s physical condition and expectation of life. In this particular case, the patient will not stay alive; there is no benefit to be obtained, and consequently, no obligation to continue the artificial feeding.
What appeared to be simply a shift of emphasis in the definitions has lead us to completely opposite answers to these moral questions. But that was only the first step. Once the notion of the expectation of a benefit became widely accepted among theologians and relegated the objective nature of the means to almost oblivion, the next stage was only a question of time…
Fr. Richard McCormick, another American Jesuit, centered the moral analysis not on the duty to preserve life, but on the quality of the life that is preserved; not on the means themselves, but on their effectiveness for the preservation of a life of such quality — the notion of the hope of benefit taken to its extreme. According to this modern trend in moral theology, to judge which treatments are ordinary or extraordinary, we have to make "value of life" judgments: granted that we can preserve this life, which kind of life are we preserving? Physical life, being a good, is nevertheless a relative good, to be preserved as the condition for interpersonal relationships; these values are the foundation of the duty to preserve physical life and dictate the limits of this duty. Consequently, physical life is not a value to be preserved when the potential for these relationships has been lost or can never be attained…
In the context of the so-called "consequentialist" theory, the moral theologian considers what is the effect that he is trying to achieve: the preservation of a life, a human life, that is, an operational rational life capable of moral acts proceeding from knowledge and free will. If this effect can be achieved, all the actions tending to it, all the means are good, ordinary, and have to be used; if it cannot be achieved, the means are useless, extraordinary, and there is no obligation to use them.. Therefore, he cannot say right off that to disconnect a respirator is a morally good or bad action. First he has to ask himself what kind of life he is preserving by the use of a respirator. If the life preserved is less than fully human, because the person is unconscious and perhaps will never recuperate the full use of his powers, its preservation is not a good, but a moral evil, and consequently all the actions and means linked to it are also evil. The analysis of a consequentialist theologian starts with a judgment on the quality of life: all means have to be used that lead to the preservation of an "operational" human life. If that kind of life cannot be achieved, there is no obligation to do anything to preserve it.
The same analysis applies to the senile, the mentally handicapped, and to anyone judged to be lacking the complete use of his reason and will. And if somebody is making this judgment, it is because the patient is considered incompetent to do it by himself. It is indeed a "brave new world," the open road to euthanasia, because somebody will have to judge if that particular life has the necessary quality to deserve preservation.
In the traditional Catholic doctrine, one of the parameters that has guided us in the judgment regarding the use of certain means to preserve life is the burden imposed by those means. In the consequentialist analysis, the burden is not imposed by the means, but by the quality of life to be preserved: the burden is the life that will be led afterwards. Has that life to be terminated because somebody judges that it is not worthy of being lived, that it cannot be lived? So, the task of the moral theologian passes over the realm of the objective evaluation of the means to preserve life, to a moral judgment about the value of one particular life.
Moral guidelines regarding different life-sustaining procedures
Let us turn now to the objective assessment of medical conditions and of life-sustaining procedures. For the moral judgment on what has to be done in a concrete case, the very first thing to be understood is the patient’s true medical condition, an assessment that can only be given by the physicians. It has to be remembered also that — even if the definition of death is a philosophical and theological question — the determination of the moment of death and of the parameters to ascertain that it has happened correspond to the physician, not to the theologian.
Moreover, the application of the means, based on their qualification as ordinary or extraordinary, depends on a clear understanding of the medical condition of the patient. One of the problems that arose in the Quinlan case was that the father appealed to the courts saying that his daughter was brain-dead; the physicians that were consulted said that she was in an irreversible coma; and in its final decision, the court said that she was in a vegetative state. That is to say, the father said that his daughter was practically dead; the physicians, that she was dying and would actually die in a foreseeable future, and the court considered that she was perhaps dying, perhaps not.
It is a scary thought that in these confusing circumstances, the court handed down a decision which since has been used as legal precedent for application in similar cases. For that reason, it is best to define the terms of our analysis.
Medical conditions of a patient
Terminal state is defined by California’s Natural Death Act (1976) as:
...an incurable condition, caused by injury, disease or illness, which, regardless of the application of life-sustaining procedures, would, within reasonable medical judgment, produce death, and where the application of life-sustaining procedures serves only to postpone the moment of death of the patient.
Coma is a generic notion, to which precisions can be added to make reference to diverse medical conditions. Taken generically, "coma" is the condition in which, because of pathological causes, there exist a reduction (up to the abolition) of the state of consciousness and of somatic vital functions (movements, sensibility, verbal expression and understanding), associated with alterations of the vegetative functions (respiration, heartbeat, blood pressure and circulation).
Deep coma is the extreme reduction of the vital and vegetative functions: the patient is inert, with alterations of breathing, without verbal or motor response, particularly to intense painful stimuli; the pupils do not react to light, the eyes are immobile; the body presents a general rigidity or becomes progressively flaccid. In the majority of cases, such a condition is not reversible. Nevertheless, there is still some slight hope of recovery, and consequently, all life-sustaining procedures must be continued, at least until the disease evolves into another stage.
The coma provoked by traumatic lesions may not remain indefinitely unchanged, but evolve into a persistent vegetative state: the patient remains unresponsive and speechless after acute brain damage, but may open his eyes and have cycles of sleeping and waking.
The upper part of the brain [cortex] is impaired but the brainstem is functioning. This is often called "brain-dead" but that description is inaccurate.
After some weeks in this condition, the possibility of a return to normal levels of consciousness is, statistically, practically nil, but some clinical improvements may appear (eye opening, some verbal and motor response), even after two years in this condition. Consequently, life-sustaining procedures, in principle, have to be continued: nutrition and respiration always, other medical treatments in so far as they allow some hope of improvement:
In the past, cessation of heartbeat and spontaneous respiration always produced prompt death of the brain, and, similarly, destruction of the brain resulted in prompt cessation of respiration and circulation. In this context, it was reasonable that absence of pulse and respiration became the traditional criteria for pronouncement of death. Recently, however, technological advances have made it possible to sustain brain function in the absence of spontaneous respiratory and cardiac function, so that the death of a person can no longer be equated with the loss of these latter two vital functions. Furthermore, it is now possible that a person’s brain may be completely destroyed even though his circulation and respiration are being artificially maintained by mechanical devices.
The criteria to establish the condition called brain-death require:
a. Prerequisite: that all the diagnostic and therapeutic procedures have been executed;
b. Criteria (which have to be verified for 30 consecutive minutes at least 6 hours after the beginning of the coma and of the apnea):
- coma with lack of cerebral response,
- apnea [i.e., lack of spontaneous respiration],
- mydriasis [i.e., excessive dilatation of the pupil of the eye],
- absence of cephalic reflexes,
- absence of electrical activity in the brain;
c. Confirmation: absence of blood flow [i.e., to the brain]. Brain death corresponds to the irreversible destruction of practically the whole brain…. Diverse studies have shown that brain death, if confirmed by rigid criteria, is always followed by somatic death, and it can therefore be taken as a sure sign of biological death [i.e., the total cessation of life in all the tissues and cells of the organs].
When all the symptoms of the "brain-death" condition are present, the patient is dead, and consequently, it is morally permissible to discontinue all life-sustaining procedures. Nevertheless, it has to be observed that the strict time limits required for the harvesting of organs for transplants demand, in their turn, immediate action after the patient has been declared brain-dead, and therefore, there is always the danger that the checking of all the symptoms or the delays required to ascertain the real existence of such a condition — that is, the real death of the prospective organ donor — will be overlooked.
"Life-sustaining procedure" is, according to California’s Natural Death Act of 1976:
...a procedure or intervention which utilizes mechanical or other artificial means to sustain, restore or supplant a vital function, which, when applied to a qualified patient, would serve only to artificially prolong the moment of death and where, in the judgment of the attending physician, death is imminent whether or not such procedures are utilized.
Standard nursing care
Standard nursing care for the patient, like hygiene, changing of bed-clothing, turning the person regularly to avoid pressure sores, etc., is an obligation in charity, and as such, has to be maintained even when there is no founded hope of survival or of regaining consciousness — that is to say, in each and every one of the medical conditions listed above.
The problem of artificial nutrition and hydration
The basic ordinary procedure for the artificial provision of nutrition and fluids is either:
...through a nasogastric tube [a tube passed down the nose into the stomach and left permanently in place for those who cannot swallow], or through a gastrostomy tube [inserted through the skin directly into the stomach].
Among the different life-sustaining procedures, the artificial provision of food and fluids poses today one of the most acute ethical problems. As infants, we were given food and drink when we were too helpless to nourish ourselves. For many of us, a day will come before we die when we will be once again too helpless to feed ourselves. Even when the struggle against disease has been lost and there is nothing more than to wait for death, it would seem that the instinctive reaction is to continue providing food and drink for the dying. This assumption is today widely challenged:
Since permanently unconscious patients will never be aware of nutrition, the only benefit to the patient of providing such increasingly burdensome interventions is sustaining the body to allow for a remote possibility of recovery...
...or, putting it more bluntly...
...it is morally justifiable to withhold antibiotics and artificial nutrition and hydration, as well as other forms of life-sustaining treatment, allowing the patient to die.
To counter these conclusions, we are convinced that the provision of food and fluids is not simply — or strictly — "medical care," but the minimum care that must be provided for the sick, whatever their medical condition. All beings need food and water to live, but such nourishment by itself does not heal or cure disease. In consequence, to stop feeding the permanently unconscious patient is not to withdraw from the battle against illness, but simply to withhold the nourishment that sustains all life.
Moreover, to withdraw the artificial provision of food and fluids is not simply "to allow the patient to die" : what we are doing is not to cease a treatment against disease, but to withdraw what is essential to sustain the life of every human being, either healthy or ill. Death will happen, not because of the illness, but because of our omission to provide adequate nutrition and hydration.
In consequence, it can be affirmed that the procedure is neither useless nor burdensome: it preserves life, and the material inconveniences that it provokes are certainly and abundantly compensated by the good that it preserves. Consequently, whatever the medical condition of the patient, artificial nutrition and hydration have to be continued.
In some very particular and extraordinary instances (as examples, in the case of a patient in a terminal condition to whom the artificial nutrition imposes a pain excessive in proportion to the very short span of life remaining, or in the case of an irreversibly demented patient who keeps tearing apart the feeding tubes and causing himself serious wounds, and who cannot be continually restrained) the inconveniences may become so burdensome that the artificial nutrition might be considered an extraordinary, non-obligatory means of preserving life.
The problem of artificial respiration
Respiration is equally basic for the preservation of life, but its artificial maintenance is nevertheless a medical procedure which replaces a vegetative function impaired or suspended by disease — that is to say, every human being breathes on his own since the moment of birth, and there is no natural stage in the development of a human being when breathing has to be assisted, the present disease is — in consequence — the direct cause of the inability to breathe.
Consequently, its use in certain medical conditions might be considered as an extraordinary means, and its withdrawal — unlike the case of withdrawal of artificial nutrition — would be this time equivalent to letting the disease continue its course, to allow the patient to die. In the case of a patient in terminal condition, that is, when death is imminent, this withdrawal is morally permissible.
In all the other conditions the procedure must be continued, unless it imposes a particularly excessive burden. As an example, in the case of a patient in a permanent vegetative state, the procedure may be discontinued if a very excessive burden caused by the procedure itself is imposed either on the patient or on his family — that is to say, artificial respiration may be withdrawn if it causes excessive, disproportionate discomfort to the patient, or if it threatens to throw the family in the most abject poverty because of the costs of maintaining it, but it cannot be withdrawn because the family does not like to see a loved one kept in such a state by a machine.
A final reminder
It is necessary here to forcefully insist on the fact that these guidelines are not a "do-it-yourself" manual to be perused on our own when the need to take decisions arises. What appears here as a simple, straightforward analysis, is, in real life, a complex and agonizing decision. No two cases are strictly identical: the medical conditions and the means at our disposal may be similar, but the subjective conditions of the applications of those means will be necessarily different, and the final moral decision will have to take into account those factors and a number of others which cannot be accurately described and evaluated in such a short exposition as this article.
It has to be remembered that the diagnosis about the medical condition of a patient corresponds to the physician, who has the knowledge and experience to ascertain the present physical condition and the prognosis of the illness, and to propose the treatments agreed upon or suggested by standard medical practice. On the other hand, the moral qualification of such means and the moral evaluation of their use in a concrete medical condition — in the light of Catholic doctrine — corresponds to the one trained to offer guidance in such decisions and who is moreover assisted by the particular graces granted by God to his state: the moral theologian, i.e., the priest. All this means that, in a concrete case, the final moral decision has to be taken after consultation with a priest, based on the medical condition of the patient objectively described and evaluated by the physicians.
This being said, it is also good to remember here some of the points we stressed before: that the qualification of some means as "ordinary" or "extraordinary" must always be referred to the objective nature of the means, and to their relationship with the subjective obstacles that may arise for their application in a concrete case. The consideration of the "usefulness" of the means must be always referred to the preservation of life, and not to any judgment of value about the "quality" of the life to be preserved. The benefit to be expected for the patient has to be estimated always in close relationship with the burdens imposed by the availability and/or use of the means.
There are only two ways in which the "quality of life" consideration of a seriously ill patient is relevant to moral decisions regarding a particular treatment:
- when the treatment creates by itself an impairment imposing new serious burdens on, or risks for, the patient; and
- when a disabling condition has a direct influence upon the benefits and burdens of a specific treatment for a particular patient.
Finally, life-sustaining procedures cannot not be withdrawn with the direct intention of causing death, but they may be withdrawn in certain medical conditions if they offer no reasonable hope of preserving life, while imposing at the same time disproportionate risks or burdens.
1 Pius XII, Allocution to Delegates at the Fourth International Congress of Catholic Doctors, September 29, 1949, in The Human Body, n.172.
2 The following paragraphs under this heading are a summary of the Appendix I, "Sviluppo e carattere dell’Etica biomedica negli USA," in Puca, Trapianto, pp.175-177.
3 Puca, op.cit., p.176, making reference to White, M. B. The Philosophy of the American Revolution, New York-Oxford, 1981.
4 Puca, op.cit., p.177.
5 Humphry, Derek. Final Exit: The Practicalities of Self-deliverance and Assisted Suicide for the Dying. Eugene: The Hemlock Society, 1991.
6 In II Tes., lect. II, n.77.
7 Summa Theologica, II-II, Q.126, A.1.
8 Cf. his Relectiones Theologicæ, IX (De Temperantia) and X (De Homicidio).
9 De Iustitia et Iure, disp.10, n.30.
10 Regatillo-Zalba, vol.II, n.254.
11 Koch-Preuss, vol.III, p.91.
12 Ubach, vol. I, n. 487.
13 Cf. the "Foreword" to The Human Body, p.9.
14 Allocution to the First International Congress of Histopathology, September 13, 1952, in The Human Body, n.359.
15 Allocution to the Scientific Congress of Sport, November 8, 1952, in The Human Body, n.404, 398.
16 Cf. "The Duty of Using Artificial Means of Preserving Life," in Theological Studies, June 1950, and "The Duty to Preserve Life," in Theological Studies, December 1951.
17 Cf. his article "To Save or to Let Die: The Dilemma of Modern Medicine," in America, July 7, 1974.
18 Puca, op.cit. pp.78 ff.
19 Puca, op.cit. p.48.
20 Puca, op.cit. p.49.
21 Puca, op.cit., p.53, quoting Jennet, B.–Bond, M., Assessment of Outcomes after Severe Brain Damage: A Practical Scale, in Lancet, 1, pp.480-484.
22 Dunn, Ethics, p.45.
23 Veith, Brain death, pp.171-172.
24 Zerbini, Prolungamento, p.47.
25 Dunn, op.cit. p.46.
26 For this whole question, a recommended reading is Meilaender, On Removing Food and Water, whose ideas are expressed in the following paragraphs.
27 The President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, "Deciding to Forego Life-sustaining Treatment," 1982, quoted in Meilaender, On Removing Food and Water, p.216.
28 Wanzer and Sydney, in the New England Journal of Medicine, April 1984, quoted in Meilaender, loc.cit.
Note: The following bibliographical references are given only to indicate the works consulted for the preparation of this article, and their quotation in no way constitutes a blanket endorsement of all their conclusions. In fact, the works here quoted range from those that uphold the traditional Catholic positions, to others which — in the opinion of the author of this article —directly oppose traditional Catholic doctrine.
Dunn, H.P. Ethics for Doctors, Nurses and Patients. New York: Alba House, 1994.
Kelly, Gerald, S.J. Medico-Moral problems [Part V]. St. Louis: The Catholic Hospital Association of the United States and Canada, 1954.
Kenny, John P., O.P. Principles of Medical Ethics. Westminster: The Newman Press, 1962 (2nd ed.).
Koch, Antony and Preuss, Arthur. A Handbook of Moral Theology. St. Louis: B. Herder Book Co., 1919-1924 [5 vols.].
Lammers, Stephen E. and Verhey, Allen (Editors). On Moral Medicine. Theological Perspectives in Medical Ethics. Grand Rapids: W.B. Eerdmans, 1989 (reprint).
Meilaender, Gilbert. On Removing Food and Water: Against the Stream. In: Shannon, Thomas A. (Editor). Bioethics […].Mahwah, NJ: Paulist Press, 1987 (3rd ed.).
O’Donnell, Thomas J., S.J. Medicine and Christian Morality. New York: Alba House, 1991 (2nd ed.)
[Pontifical Academy of Science]. Prolungamento artificiale della vita. Vatican City: Libreria Editrice Vaticana, 1987.
Puca, Antonio, M.I. Trapianto di cuore e morte cerebrale (Aspetti ettici). Turin: Edizione Camilliane, 1993.
Regatillo, E.F. S.J.–Zalba, M. S.J. Theologiæ Moralis Summa. Madrid: Biblioteca de Autores Cristianos, 1953 [3 vols.].
Shannon, Thomas A. (Editor). Bioethics. Basic writings on the key ethical questions that surround the major modern biological possibilities and problems. Mahwah, NJ: Paulist Press, 1987 (3rd ed.).
[Solesmes-Papal Teachings]. The Human Body. Boston: St. Paul Editions, 1979.
Sparks, Richard C.C.S.P. To Treat or Not To Treat. Bioethics and the Handicapped Newborn. Mahwah, NJ: Paulist Press, 1988.
Tissier de Mallerais, Bernard, Fr. (et al.). Le Respect de la Vie: La Doctrine de l’ Eglise. Escurolles: Fideliter, 1988.
Ubach, Jose, S.J. Theologia Moralis. Buenos Aires: Sebastian de Amorrurtu, 1935 (2nd ed.) [2 vols.].
Veith, Frank J. (et al.). Brain Death. In: Shannon, Thomas A. (Editor). Bioethics […].Mahwah, NJ: Paulist Press, 1987 (3rd ed.).
Walter, James J.–Shannon, Thomas A. (Editors). Quality of life. The new medical dilemma. Mahwah, NJ: Paulist Press, 1990.
Zerbini, E.J. Il prolungamento della vita e I criteri della morte. In: [Pontifical Academy of Sciences]. Prolungamento artificiale della vita. Vatican City: Libreria Editrice Vaticana, 1987.