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  1. The Catholic Tradition of A Good Death: Emerging Implications Nuala Kenny SC OC, MD, FRCP Professor Emeritus Department of Bioethics Dalhousie UniversityEthics & Health Policy Advisor Catholic Health Alliance of Canada

  2. A Good Death “Where, O death, is your victory? Where, O death, your sting?

  3. In This Reflection I Plan to: • Consider the context of dying today • Reflect on the Catholic tradition of a ‘good death’ • Identify some lessons regarding health decisions and end of life care for: • Persons and their loved ones • Professionals • Parishes • Public policy

  4. Dying in North America We are a death-denying, death-defying culture ¼ million die each year; 75% over 65yrs 75% die in hospital and long term care; majority under aggressive treatment for cure Catholics are among the most likely to be still undergoing aggressive treatment at death! 5-10% receive integrated palliative end of life care

  5. Confusion re A Good Death Polls show confusion about end of life care, patients’ rights and duties and the goals and effectiveness of palliative care, especially Refusal of care Withdrawal/withholding on non-beneficial care Pain and symptom control There are different visions of a ‘good death’ Assisted death-euthanasia and assisted suicide Modern hospice and palliative care The long Catholic tradition

  6. “Whoever lives and believes in me shall never die” John 11:26

  7. The Long Catholic Tradition on Health Care Decisions (Since 16thC) • Life and physical health are precious gifts entrusted to us by God. We must take reasonable care of them, taking into account the needs of others and the common good. • Catechism #2288 • If morality requires respect for the life of the body, it does not make it an absolute value. • Catechism #2289

  8. The Long Catholic Tradition on Health Care Decisions (Since 16thC) • If morality requires respect for the life of the body, it does not make it an absolute value. • Catechism #2289

  9. Pope Pius XII 1957 • “(N)ormally one is held to use only ordinary means-according to circumstances of persons, places, times and culture-that is to say, means that do not involve any grave burden for oneself or another. A more strict obligation would be too burdensome for most men and would render the attainment of the higher, more important good too difficult. Life, health, all temporal activities are in fact subordinated to spiritual ends.”[14]

  10. CDF 1980 Declaration on Euthanasia • “It will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her moral resources.”[15] .

  11. Relief of Pain and Suffering • “While pain and suffering are to be relieved at all cost, when accepted in faith suffering does have redemptive value…This does not mean that God takes pleasure in human pain and suffering. Nor does it mean that Christians are to be passive in accepting suffering and not to strive to alleviate or eradicate it at its source” • Catholic Health Ministry and the Catholic Church in Canada, no.7

  12. Nutrition and Hydration: Special Concerns • Confusion about the obligation to take/provide medically assisted nutrition and hydration, especially at end of life • Special concerns re nutrition and hydration : • Social and ethical significance of feeding • Anorexia at the end of life is normal • The importance of non-abandonment and ordinary care • The 2004 Papal Allocution

  13. The 2004 Papal Allocution “…the administration of water and food, even when provided by artificial means, always represents a naturalmeans of preserving life and not a medical act. Its use, furthermore, should be considered in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have achieved its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering.”(no4)

  14. US Bishop’s Clarification • “In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic and presumably irreversible conditions (e.g., the “persistent vegetative state”) who can reasonably be expected to live indefinitely if given such care.

  15. Clarification con’t • Medically assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be ‘excessively burdensome for the patient or (would) cause significant physical discomfort, for example resulting from complications in the use of the means employed.’ • For instance, as a patient draws close to inevitable death from an underlying progressive and fatal condition, certain measures to provide nutrition and hydration may become excessively burdensome and therefore not obligatory in light of their very limited ability to prolong life or provide comfort (ERD # 58).

  16. Accepting limits • “Human life, however, has intrinsic limitations, and sooner or later it ends in death. This is an experience to which each human being is called, and one for which he or she must be prepared” • Pope Benedict XVI Message for the World Day of the Sick February 11, 2008

  17. Accepting Death & The Limits of Medicine When death is clearly imminent and inevitable, one can in conscience “refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted” Declaration on Euthanasia “Iura et Bona” 1980

  18. Refusal of Non-beneficial & Unduly Burdensome Care “ To forego extraordinary of disproportionate means is not the equivalent of suicide or euthanasia; it rather expresses acceptance of the human condition in the face of death” John Paul II Evangelium Vitae,no.66 1995

  19. Rejecting Euthanasia and Assisted Suicide “ Euthanasia is a false solution to the drama of suffering, a solution unworthy of man. Indeed, the true response cannot be to put someone to death, however ‘kindly’ but rather to witness to the love that helps people to face their pain and agony in a human way” (Pope Benedict XVI, Angelus message 1 February, 2009)

  20. So, in summary Life is a basic but limited good; we have an obligation to protect and preserve prudently The obligation to prolong life is evaluated in light of one’s medical condition and ability to pursue the spiritual goods of life The determination of benefit and burden belongs to the patient

  21. Summary con’t • We are morally obliged to use medical means that offer reasonable hope of benefit without imposing excessive burden • We are not obliged when death is imminent and medicine only prolongs the dying; there is no reasonable hope of benefit or treatment imposes excessive burden • Burden is understood broadly-physical, psychological, social and spiritual • We accept suffering; we work toward pain and other physical symptom alleviation

  22. Some cases:Pope John Paul II

  23. Implications and Lessons • For individuals • For their loved ones • For professionals who care for the dying • For communities and parishes • For public policy

  24. For individuals and their loved ones We need to take prudent care of our life and health We should take informed (prayerful) decisions Refusal of Rx by competent patients allowed We should see advance care planning as primarily a spiritual event Clarifying values Conversation, conversation Make an advance directive

  25. For professionals who care for the dying • The importance of care and non-abandonment • Respect for spiritual/religious values • Withdrawal/withholding of non-beneficial/burdensome Rx is allowed • Application of the goals of palliative care: • Pain and symptom control • Support for the ‘last things’ • Concern for family and loved ones • Importance of ‘presence’ and non-abandonment

  26. For communities and parishes • We all have an obligation to care for the sick, the dying and their care-givers • We assume professional caregivers and services will do everything • Parish pastoral care for the sick, handicapped, dying, bereaved is a crucial element in our understanding of community

  27. For public policy • POLST vs advance care planning • Legalization of assisted death • Understand the consequences of legal change • Hospice & Palliative care as national priority • Advocate for improvement in access & quality • Concern re the privatization (profitization) of end of life care • Support for caregivers • Crucial need for options and for respite care

  28. Principle of Double Effectcontinued • There are two effects, one good and one bad; the action is good in itself. • one sincerely intends to produce the good effect • the good effect is not achieved through the bad effect • the good intended is proportionately greater than the bad that is foreseen but not intended

  29. Important Issues with PDE • Morality is not entirely dependent on consequences • Intention is important • Intention is not belief or desire • Intention is not motive • Dosage, intention and action • ‘Screening questions’ for intent