THE ETHICS of END-OF-LIFE HEALTH CARE, PART V: THREE QUESTIONS

When illness or injury threaten to end our lives or the lives of our loved ones, we may well find ourselves confronted with difficult decisions. Should we try this treatment or not? Should we try to resuscitate Mom? Should we withdraw life-support? How, in the specific situations of our lives, can we determine which life-sustaining measures are ordinary, and therefore obligatory, and which are extraordinary and non-obligatory? Put another way, how can we distinguish between life-sustaining measures that cannot be omitted without the will to cause death, and those that can be omitted such that “one does not will to cause death; one’s inability to impede it is merely accepted” (CCC 2278)?

In some cases the answers will be obvious. We must feed our children and bandage their wounds. Those are ordinary means of preserving life. We don’t need to have our bodies cryogenically frozen in hopes that we might some day be resuscitated. That would clearly be extraordinary. But sometimes answers are not obvious. So how can we distinguish between ordinary and extraordinary means when the decisions we must make are difficult? We can do so by asking and answering three questions:

1. Is it a medical procedure or normal care?

This first question helps us determine the kind of life-preserving measure we are considering. Is it a medical procedure that has the purpose of treating illness, whether from sickness or injury? Or is it a kind of care that would need to be provided whether the person was ill or not? This kind of care is what Pope Saint John Paul II has called “normal care,” the purpose of which is not to treat illness but to provide things like food and shelter that are always needed to sustain life and health. Pope Saint John Paul II declared that provision of food and water, even by artificial means, should be considered normal care.

The purpose of normal life-sustaining care is simply to sustain life and health. Such care is necessary whether or not a person is sick. So when we evaluate the benefits of such care, we do so based on its capacity to sustain life, not on its usefulness in curing illness. Feeding someone, so long as the food is effectively providing nourishment, is beneficial. It does not cease being beneficial when the person who receives it becomes terminally ill.

Artificial nutrition and hydration are considered normal care. However, using a ventilator to support breathing is not. That doesn’t mean that either is necessarily right or wrong. It means that, as a medical procedure, the benefits of artificial ventilation will be identified in relation to its medical purpose, whereas the benefits of nutrition and hydration will be identified in relation to their purpose of providing life-sustaining nourishment.

2. What are the burdens and benefits?

This question has to do with the outcomes that are likely to result from the procedure or form of care being considered. Beneficial outcomes are those that fulfill the procedure’s purpose. In the case of feeding, the successful provision of life-sustaining nourishment is counted as a benefit. In the case of ventilation, the successful treatment of illness is the benefit being sought. When illness is no longer treatable, even if life can no longer be sustained apart from ventilator-assisted respiration, use of a ventilator need no longer be considered beneficial.

The burdens we are considering are the undesirable outcomes of a given procedure. For example, the unwanted side effects of chemotherapy or the risks associated with surgical procedures. It is important to recognize that the burdens we are considering do not include all the undesirable features of a person’s life. If someone suffers from depression, for example, that is not a good reason to refuse life saving heart surgery. The choice to forego life saving treatment, in that case, would not be about avoiding burdensome outcomes of the procedure, but about ending a burdened life. As much as we must sympathize with such a person, that choice would be suicidal.

3. Are the benefits proportionate or disproportionate to the burdens?

Once we have considered the burdens and benefits of the procedure or form of care in question, we must weigh them against one another. Sometimes this yields a clear, objective answer. When artificial feeding achieves the benefit of providing nourishment and only involves the burdens of having to periodically sanitize the tubes and change the bags, the benefit clearly outweighs the burdens. This form of care is therefore proportionate and an ordinary means of preserving life. Sometimes the answer is not so clear, as when a form of care involves both significant burdens and significant benefits. In these cases, the decisions may indeed be difficult, involving the careful weighing of many factors. When we face such difficult decisions, however, we can be confident that, by asking the right questions, we will arrive at ethically sound answers and make blameless and morally upright decisions.

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