THE ETHICS of END-OF-LIFE HEALTH CARE, PART IV: MEDICAL and NON-MEDICAL CARE

In our consideration of end-of-life health care, we seek to understand how we can determine which potentially
life-sustaining measures are to be considered ordinary means of preserving life and which should be considered extraordinary means. From our previous posts, we know that the term “ordinary means” applies to safe, beneficial methods of preserving life in which the expected benefits proportionately outweigh the expected burdens. The term “extraordinary means,” by contrast, refers to possible life-sustaining measures that are risky or burdensome to the extent that the burdens outweigh the benefits (see CCC 2278).

To determine whether a potentially life-saving measure is an ordinary or extraordinary means, we must consider whether or not the expected burdens outweigh the likely benefits. A medical procedure that, in the language of the Catechism, has burdens “disproportionate to the expected outcome,” should be considered extraordinary and therefore unnecessary. It is important to remember, however, that the “proportion” the Catechism refers to is the proportion between the benefits and burdens of a particular procedure, not the totality of positives and negatives in a person’s life. One might legitimately decide that a particular medical procedure is too burdensome to be continued. That is not the same as deciding that a person’s life is too burdensome to be continued.

It is also important to consider that there are means of preserving life that are not medical procedures. Eating and drinking, breathing in oxygen, taking shelter, and providing warmth are all means of preserving life that are not medical. The passage from the Catechism that we have been referring to is explicitly about “medical procedures.” But what if the life-sustaining measure under consideration is not a medical procedure? How, if at all, does that affect our consideration of whether it is an ordinary or extraordinary means of preserving life?

Pope Saint John Paul II answered this question in a March 20, 2004 address in which he considered the use of artificially administered nutrition and hydration. The Pope declared, “The administration of water and food, even when provided by artificial means, always represents a natural means of preserving life.” He therefore concluded that the artificial administration of water and food “should be considered, in principle, ordinary and proportionate, and as such morally obligatory.”

The pope calls artificially administered water and food “normal care” and “a natural means of preserving life.” He explicitly contrasts “natural means” of preserving life with “medical acts.” Medical acts are for the purpose of healing or at least treating injury, illness, or disease. The kinds of care Pope Saint John Paul II identifies as “natural means” are not for those purposes. They are ways of sustaining life that are necessary whether a person is ill or not.

The pope’s conclusion – that artificially administered food and water “should be considered, in principle, ordinary and proportionate, and as such morally obligatory” – clearly indicates that “medical acts” and non-medical “natural means” are to be evaluated differently. Medical acts are to be evaluated based on their capacity to treat illness. Non-medical forms of care are not to be evaluated on that basis. They are to be evaluated based on their capacity to achieve their purpose. Feeding, for example, should be considered effective so long as it provides nourishment. To put it in another way, the effects of medical procedures are considered beneficial insofar as they effectively treat illness. If chemotherapy has no prospect of treating a person’s cancer, it is of no benefit. Effects of non-medical care are not judged solely by medical outcomes. If feeding provides life-sustaining nourishment, it is beneficial, even if it does nothing to cure a debilitating illness.

That is why Pope Saint John Paul II concluded that the administration of artificial water and food “should be considered, in principle, ordinary and proportionate, and as such morally obligatory.” These are considered ordinary and obligatory so long as they provide the life-sustaining benefits of hydration and nutrition without, at the same time, imposing countervailing burdens. By saying artificially administered water and food is “in principle” ordinary and obligatory, the Pope acknowledges that administering water and food is not ordinary and obligatory in every case. If administering food or water fails to achieve its life-sustaining purpose or if it is a source of discomfort or bodily harm, it could then be considered an extraordinary means of preserving life and therefore might rightly be foregone or discontinued.

The difference between a medical act and a natural, non-medical, means of preserving life is not that the latter are always ordinary and obligatory. The difference is in how their burdens and benefits are evaluated. The provision of food and water, even artificially, is beneficial so long as it achieves its life-sustaining purpose, irrespective of medical outcomes.

Pope Saint John Paul II’s complete address is available here.

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