I have set before you life and death . . . Choose life (Deuteronomy 30:19).

With these words, Moses exhorts God’s people to follow God’s law and thereby receive His life-giving blessings. We might, however, take the liberty of reapplying these words in our consideration of health care ethics, where they can be understood as articulating a fundamental principle: Always choose life; never choose death.

This principle is especially important when we consider the ethics of end-of-life health care. Toward the end of a person’s life, decisions are often made that lead either to the preservation of that person’s life or to the preparation for that person’s death. In every case, we are to choose life. In some cases, however, we rightly choose to accept death and to prepare for it. To understand how this is so, we must consider the Church’s distinction between “ordinary” and “extraordinary” means of preserving life.

Ordinary means of preserving life are life-sustaining measures that we are obliged to take for ourselves and those in our care. If one voluntarily neglect to feed his children, for example, he deserves blame. He has failed to take an ordinary means of preserving life and health for those in his care. When we do preserve life by such ordinary means, we choose life. When we feed our children, we choose to bring about their continued life and health. When we voluntarily neglect to feed our children and they die as a consequence, we effectively choose death. By choosing not to sustain life by ordinary means, we bring about death.

Extraordinary means of preserving life are life-sustaining measures that we are not obliged to take. If we refuse to subject ourselves to chemotherapy that would be painful and likely ineffective, we are doing nothing wrong. The alternative to such treatment may be to prepare for death. But accepting death is not the same as choosing death. In such a case, the refusal of treatment is not what causes death. By choosing not to take extraordinary means to preserve life, we do not bring about death. We still choose life, even as we accept death.

When a patient or a patient’s loved one is faced with a difficult decision about potentially life-sustaining treatment, it can often seem like a choice between life and death. When it is a decision about extraordinary means of preserving life, however, it is not a choice between life and death. The choice to forego extraordinary treatments is not a choice to cause death. In such a case, it is the illness, and not anything anyone chose to do or not do, that brings about the patient’s death. The choice is not between life and death, but between accepting the treatment and refusing it. When someone decides to refuse extraordinary treatment, that doesn’t mean she has chosen death. On the contrary, she continues to choose life by making use of the ordinary life-sustaining means at her disposal.

The difference between ordinary and extraordinary means of preserving life directly correlates with a difference in what one wills. Thus, to say that something is an ordinary means of preserving life is to say that, by foregoing it, one wills to cause death. To say that something is an extraordinary means, as the Catechism explicitly states, means that by foregoing or discontinuing it “one does not will to cause death; one’s inability to impede {death} is merely accepted” (CCC 2278).

To say that refusing ordinary means of preserving life is tantamount to choosing death is to say that, objectively, it constitutes murder or suicide. To starve someone to death is to murder her. To leave a slit in one’s wrist un-bandaged is to commit suicide. That is not to say, however, that everyone who declines ordinary means of preserving life is subjectively guilty of murder or suicide. To say that someone has chosen to cause death does not necessarily mean that person is aware of having done so. In the case of suicide, the person’s choice will almost always be compromised by mental illness. In the case of murder or assisted suicide, the choice to cause another’s death might be motivated by honorable goals, like sparing someone from pain and suffering. The person who chooses to cause death may only consider the goodness of the primary goal of avoiding suffering and not the evil of the choice to cause death. Although forgoing ordinary means of preserving life always implies the will to cause death, a person can be more or less ignorant of that and therefore more or less responsible for his wrongdoing.

Distinguishing between ordinary and extraordinary means of preserving life can be difficult. It is easier to think about what we are and are not choosing. We are not choosing between life and death. We always choose life. We may, however, need to choose between pursuing and forgoing potentially life-sustaining treatments. Sometimes we can rightly choose to forgo such treatments. When we do that, we do not choose to cause death. Rather, we accept that death can no longer be reasonably forestalled and the time has come for us or our loved ones to prepare to meet the Lord who alone gives life without end.