END OF LIFE ISSUES UNIVERSITY OF DAYTON FATHER EARL K. FERNANDES, STD DEAN, ATHENAEUM OF OHIO MARCH 15, 2014
The Human Person Made in the image and likeness of God. Inherent Dignity Unity of Body and Soul Intellect: Able to know the good. Free Will: Able to Choose the Good
Attributed and Inherent Dignity Attributed/Personal Dignity Particular Individualistic Contingent We perceive its loss “undignified” Suffering “indignities” • Inherent/Basic Dignity • Universal • Inalienable • Inviolable • Loss of attributed/personal dignity reflects the importance of inherent dignity
The End of Life and the telos of Medicine • What role do physicians have when patients and families either confront death or desire it? • Is medicine’s goal to prolong life? • To preserve only the quality of life until it subjectively becomes unbearable for either the patient or society?
YES: Intent is different and agent is different (killing involves a person as the proximate cause of death; letting die involves the disease) Euthanasia is impermissible Principle of the Double Effect NO: Outcome (death of the person) is the same Allows the hastening of death (euthanasia) Pain control (narcotics) which decrease respirations is really just euthanasia Killing versus Letting Die: Is there a difference?
Killing versus Letting Die: Is there a difference? • There is an ethical distinction between euthanasia and “allowing to die.” • Pro-euthanasia proponents attack this distinction with great energy: • False distinction • Really just “passive euthanasia” • Involves the intent to end the suffering of the patient by killing them as much as “active euthanasia” which involves, say, a syringe filled with morphine.
Killing versus Letting Die: Is there a difference? • The Catholic distinction is strong: • Insists upon a clear distinction of the intention of the moral agent. • Example of the Two Dentists: • Dentist #1 wants to relieve the patient’s suffering due to toothaches; the dentist knows an extraction is necessary. The dentist foresees an effect of the extraction- pain, but does not intend it. The dentist carries out the extraction to relieve suffering. • Dentist # 2 is a masochist. He enjoys seeing his patients suffer during extraction. He extracts the tooth in the most painful way possible. Dentist 2 intends the suffering of his patient; he doesn’t merely foresee it.
Killing versus Letting Die: Is there a difference? • The distinction between directly willing the death of a human person—which is euthanasia and the willing to end a disproportionate intervention that no longer offers “reasonable hope of benefit or imposes an excessive burden,” (ERD, 56) must be kept absolutely clear. • The rejection of certain medical measures is not a rejection or diminishing of life itself or of God’s Providence—but a reasonable choice to discontinue well-meaning, but ethically ineffective interventions.
Killing versus Letting Die: Is there a difference? • Letting someone die means allowing someone who is dying from some underlying condition to die. • One foresees that the individual will die but chooses not to prolong life. It is permissible when: • The death of the person is not willed; and • When one does not withhold some ordinary, morally obligatory treatment. • Allowing a person to die (even death itself) can lead to a great good: the journey of the soul from this life to the next.
Euthanasia and Physician-Assisted Suicide (PAS): Vocabulary • What is euthanasia? • Literally, the term means “good death” but in common parlance it has come to mean “mercy killing” to alleviate suffering. • This mercy killing is often seen as preferable to suffering from either physical or mental incapacity. • In ancient Greece and forward this act was done with or without the person’s permission.
Euthanasia and Physician-Assisted Suicide (PAS): Vocabulary • How does the Catholic Church define euthanasia? • “Euthanasia is understood as any action or omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated. Euthanasia’s terms of reference, therefore, are to be found in the intention of the will and in the methods used.”
Euthanasia and Physician-Assisted Suicide (PAS): Vocabulary • Types of Euthanasia: • Direct euthanasia refers to killing a patient intentionally as a means or an end. • Direct euthanasia can be done directly either by commission or omission. • Active euthanasia: An example of direct euthanasia by commission is giving someone a lethal injection • Passive Euthanasia: Euthanasia by omission would be failing to provide someone with morally obligatory treatment or care in order to kill the patient.
Euthanasia and Physician-Assisted Suicide (PAS): Vocabulary • Types of Euthanasia: • Voluntary euthanasia refers to a situation in which a patient asks to be killed. • Non-voluntary euthanasia refers to a situation in which a person has not indicated whether he or she wants to end his or her life. • Involuntary euthanasia refers to a situation in which a person is killed against his or her own will.
Euthanasia and Physician-Assisted Suicide (PAS): An Example • Almost everyone agrees that killing a person against his will is wrong: • whether by directly killing the person or • by allowing the person to die when one could easily (reasonably) save the person’s life. • There is no moral difference between the two. • Let us imagine that I don’t like John. • One day we are swimming in a pond. • When John is least expecting it, I hit John over the head with a rock, hold his head under water, and drown him. • I have actively and directly killed him. • This is direct killing.
Euthanasia and Physician-Assisted Suicide (PAS): An Example Let us imagine John is in the pond and I am at the edge of the pond. The water is not too deep and I am a good swimmer. John catches his feet on some weeds and is trapped and begins to drown. I could easily pull him out and rescue him. He calls for help, but I remember that John swindled me out of $100. I keep on walking saying that he deserves it. I could have reasonably saved him. • Even though I didn’t do anything actively against him, my actions are morally the same as if I had drowned him.
Euthanasia and Physician-Assisted Suicide (PAS): An Example • A medical example: • A doctor gives a terminally ill patient a lethal injection. He actively kills him. • This is the moral equivalent of failing to put a simple tourniquet on a bleeding man’s arm in order to kill him.
Persistent Vegetative State • For many years Catholic theologians have debated the proper (obligatory) care for patients in Persistent Vegetative State (PVS) or patients with persistent cognitive deprivation. • Such patient’s are not “brain dead”; they lack cognitive awareness (reason).
Persistent Vegetative State • Some argue that such people lack consciousness and can no longer interact with society. • They argue that the person has ceased to exist when the capacity to reason has been effectively eliminated. • Others simply argue that such patients’ lives are not worth living.
Persistent Vegetative State: Nutrition and Hydration • Others do not enter into the quality of life issue. • They believe in the dignity of the person. • They assert that patients in PVS should be allowed to pursue the spiritual (Ultimate) good and that prolongation of life through nutrition and hydration prevents this. • They argue that nutrition and hydration is not obligatory (ordinary) for these patients.
Nutrition and Hydration & PVS:John Paul II’s Allocution (2004) Pope John Paul II gave an allocution to the International Congress on “Life Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas,” on March 20, 2004.
Nutrition and Hydration & PVS:John Paul II’s Allocution (2004) “The sick person in a vegetative state, awaiting recovery or a natural end, still has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.), and to the prevention of complications related to his confinement to bed. He also has the right to appropriate rehabilitative care and to be monitored for clinical signs of eventual recovery.”
Nutrition and Hydration & PVS:John Paul II’s Allocution (2004) “I should like particularly to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, 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 attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering.”
Nutrition and Hydration & PVS:John Paul II’s Allocution (2004) “… insofar as and until it is seen to have attained its proper finality”: The Pope is not claiming that food and water must be given in all circumstances. If a patient cannot assimilate food and water, then there is not strict obligation to administer them. If a patient is imminently dying and his bodily system can no longer make use of nutrition and hydration, there is no need to provide food and water to them.
Nutrition and Hydration & PVS:John Paul II’s Allocution (2004) “The obligation to provide the "normal care due to the sick in such cases" includes, in fact, the use of nutrition and hydration. The evaluation of probabilities, founded on waning hopes for recovery when the vegetative state is prolonged beyond a year, cannot ethically justify the cessation or interruption of minimal care for the patient, including nutrition and hydration. Death by starvation or dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission.” John Paul II did not speak of nutrition and hydration as treatment but as basic care.
Nutrition and Hydration & PVS:USCCB Dubia • Some questioned the weight of the Allocution and its teaching. • Some argued that the speech was written for a particular audience by a “ghost writer”. • The USCCB presented dubia to the Congregation for the Doctrine of the Faith. • These received a response on Aug 1, 2007.
Nutrition and Hydration & PVS:USCCB Dubia • First question: Is the administration of food and water (whether by natural or artificial means) to a patient in a “vegetative state” morally obligatory except when they cannot be assimilated by the patient’s body or cannot be administered to the patient without causing significant physical discomfort? • Response: Yes. The administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life. It is therefore obligatory to the extent to which, and for as long as, it is shown to accomplish its proper finality, which is the hydration and nourishment of the patient. In this way suffering and death by starvation and dehydration are prevented.
Nutrition and Hydration & PVS:USCCB Dubia • Second question: When nutrition and hydration are being supplied by artificial means to a patient in a “permanent vegetative state”, may they be discontinued when competent physicians judge with moral certainty that the patient will never recover consciousness? • Response: No. A patient in a “permanent vegetative state” is a person with fundamental human dignity and must, therefore, receive ordinary and proportionate care which includes, in principle, the administration of water and food even by artificial means.
Nutrition and Hydration & PVS:Ethical and Religious Healthcare Directives The Ethical and Religious Directives were revised in 2009 to bring them into conformity with the statements of the JP II and the CDF: “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.”
Nutrition and Hydration & PVS:Ethical and Religious Healthcare Directives What does the 5th ed. Of the Directives say? • “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.””
Nutrition and Hydration & PVS:Ethical and Religious Healthcare Directives What does the 5th ed. Of the Directives say? • “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 non-obligatory in light of their very limited ability to prolong life or provide comfort.”