2. Catholic Moral Tradition & Health Care Principles In a Presented by Rev. James T. Bretzke, S.J., S.T.D. bretzke@bc.edu http://www.usfca.edu/fac-staff/bretzkesj/USFWebIndex.htm

3. Catholic Teaching: True or False? #1: Medical treatment must always be continued, as long as it provides some medical benefit to the patient. #1: Medical treatment must always be continued, as long as it provides some medical benefit to the patient. #2: Some medical procedures or drugs are always morally required (such as feeding tubes). #2: Some medical procedures or drugs are always morally required (such as feeding tubes). #3: Pain medication which would hasten death is not permitted. #3: Pain medication which would hasten death is not permitted. #4: Living wills in which one elects not to pursue aggressive treatment are not permitted. #4: Living wills in which one elects not to pursue aggressive treatment are not permitted. #5: The Church is opposed to the notion of “death with dignity.” #5: The Church is opposed to the notion of “death with dignity.” #6: In cases of terminal illness the Church opposes hastening or ending a life to end that pain #6: In cases of terminal illness the Church opposes hastening or ending a life to end that pain

4. 4 Health Care Principles Autonomy (respecting the individual’s decision-making capabilities, other things being equal) Autonomy (respecting the individual’s decision-making capabilities, other things being equal) Beneficence (care which weighs risks in light of benefits to the patient) Beneficence (care which weighs risks in light of benefits to the patient) Non-Maleficence (and which does not cause undue harm: Primum non nocere) Non-Maleficence (and which does not cause undue harm: Primum non nocere) Justice (fairness in distribution of risks, benefits and limited health-care resources) Justice (fairness in distribution of risks, benefits and limited health-care resources) None of these principles is “stand-alone”; they must be considered in relation to the others, and the common good is crucial in weighing these None of these principles is “stand-alone”; they must be considered in relation to the others, and the common good is crucial in weighing these

7. End of Life Ethical Issues Death with Dignity Living wills Palliative Care Euthanasia Active Active Passive Passive What does “dignity” mean? AHCDs are morally acceptable Pain management is morally acceptable, EVEN if death is hastened Euthanasia is not morally acceptable

9. Extraordinary Means All medicines, treatments, and operations, etc. that All medicines, treatments, and operations, etc. that (1) do not offer a reasonable hope of success or reasonable benefit to the patient; and/or (1) do not offer a reasonable hope of success or reasonable benefit to the patient; and/or (2) which cannot be obtained or used without excessive hardship— (2) which cannot be obtained or used without excessive hardship— i.e., excessive pain, cost, or other inconvenience i.e., excessive pain, cost, or other inconvenience Either directly to the patient, or the the patient’s network of close relationships (e.g., the family) Either directly to the patient, or the the patient’s network of close relationships (e.g., the family)

10. Discerning “Extraordinary” Means Catechism of the Catholic Church [CCC] #2278 Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of "over-zealous" treatment. Here one does not will to cause death; one's inability to impede it is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected. Catechism of the Catholic Church [CCC] #2278 Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of "over-zealous" treatment. Here one does not will to cause death; one's inability to impede it is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected.

11. Using Extraordinary Means To label a medical therapy, etc., “extraordinary” does not mean that it is morally suspect or prohibited To label a medical therapy, etc., “extraordinary” does not mean that it is morally suspect or prohibited Rather it simply means that such a procedure, etc. is not “morally obligated” Rather it simply means that such a procedure, etc. is not “morally obligated” “Extraordinary” does (usually) NOT mean “extreme” or “heroic” “Extraordinary” does (usually) NOT mean “extreme” or “heroic” And therefore its use or non-use would have to be determined according to different criteria of discernment And therefore its use or non-use would have to be determined according to different criteria of discernment Some examples…. Some examples….

12. Ordinary Means Are the “opposite” of extraordinary means, and which are seen as necessary to preserve life and/or health, Are the “opposite” of extraordinary means, and which are seen as necessary to preserve life and/or health, And which are not excessively burdensome And which are not excessively burdensome And have a good chance of success (e.g., not considered to be “experimental”) And have a good chance of success (e.g., not considered to be “experimental”) And which are well-established in the medical “culture” of the given situation And which are well-established in the medical “culture” of the given situation “Ordinary” does not (necessarily) mean “routine” “Ordinary” does not (necessarily) mean “routine” All “ordinary means” are considered to be morally obligatory, and therefore required All “ordinary means” are considered to be morally obligatory, and therefore required

13. Comparison of “Ordinary” & “Extraordinary” Means “Ordinary” Does NOT mean “usual, routine, or unexceptional” “Ordinary” Does NOT mean “usual, routine, or unexceptional” Instead it means “full, complete, required” Instead it means “full, complete, required” In medicine “food and water” would normally (but NOT always) be considered “ordinary” means of health care In medicine “food and water” would normally (but NOT always) be considered “ordinary” means of health care “Extraordinary” does NOT mean “extreme, heroic, exceptional, or rare” Rather it means “supplementary, additional, above and beyond what is required” In medicine, an experimental drug would be “extraordinary” health care

14. Or In Other Words… “Ordinary” means are morally obligatory “Ordinary” means are morally obligatory “Extraordinary” means are not morally obligatory “Extraordinary” means are not morally obligatory Use/Non-use of extraordinary means depends on a weighing of values, disvalues, benefits, and consequences Use/Non-use of extraordinary means depends on a weighing of values, disvalues, benefits, and consequences Both ordinary and extraordinary means are “decided” in reference to the concrete individual, and never just in the abstract Both ordinary and extraordinary means are “decided” in reference to the concrete individual, and never just in the abstract The Vatican prefers the term “proportionate” & “disproportionate” CDF Jura et bona (Declaration on Euthanasia), 1980 The Vatican prefers the term “proportionate” & “disproportionate” CDF Jura et bona (Declaration on Euthanasia), 1980

15. Subjective Relationship to a Particular Patient Is the Key! The discernment over what constitutes ordinary and extraordinary means can not be given in the abstract like answers in the back of a textbook The discernment over what constitutes ordinary and extraordinary means can not be given in the abstract like answers in the back of a textbook What is “ordinary” in one instance would be “extraordinary” in another What is “ordinary” in one instance would be “extraordinary” in another What is “ordinary” for one patient would be “extraordinary” for another, including psychological burden What is “ordinary” for one patient would be “extraordinary” for another, including psychological burden Vehemens horror principle in the moral tradition Vehemens horror principle in the moral tradition “Subjective Relationship does NOT equal “relativism” “Subjective Relationship does NOT equal “relativism”

16. Subjectivism Has Limits Though

18. Euthanasia Morally Unacceptable CCC #2277 Whatever its motives and means, direct euthanasia consists in putting an end to the lives of handicapped, sick, or dying persons. It is morally unacceptable. Thus an act or omission which, of itself or by intention, causes death in order to eliminate suffering constitutes a murder gravely contrary to the dignity of the human person and to the respect due to the living God, his Creator. The error of judgment into which one can fall in good faith does not change the nature of this murderous act, which must always be forbidden and excluded CCC #2277 Whatever its motives and means, direct euthanasia consists in putting an end to the lives of handicapped, sick, or dying persons. It is morally unacceptable. Thus an act or omission which, of itself or by intention, causes death in order to eliminate suffering constitutes a murder gravely contrary to the dignity of the human person and to the respect due to the living God, his Creator. The error of judgment into which one can fall in good faith does not change the nature of this murderous act, which must always be forbidden and excluded

20. Distinction: Euthanasia vs. O/E Means Euthanasia must be distinguished from the decision to forego so-called "aggressive medical treatment", in other words, medical procedures which no longer correspond to the real situation of the patient, either because they are by now disproportionate to any expected results or because they impose an excessive burden on the patient and his family. In such situations, 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". Certainly there is a moral obligation to care for oneself and to allow oneself to be cared for, but this duty must take account of concrete circumstances. It needs to be determined whether the means of treatment available are objectively proportionate to the prospects for improvement. To forego extraordinary or disproportionate means is not the equivalent of suicide or euthanasia; it rather expresses acceptance of the human condition in the face of death. Pope John Paul II, Evangelium vitae, #65.

21. Nor Is Vitalism Acceptable “Vitalism” means maintaining biological life at all costs “Vitalism” means maintaining biological life at all costs This is not the teaching of the Catholic Church This is not the teaching of the Catholic Church Nor does it reconcile with belief in the Resurrection Nor does it reconcile with belief in the Resurrection “After all, life on earth is not an "ultimate" but a "penultimate" reality” Evangelium vitae, #2 “After all, life on earth is not an "ultimate" but a "penultimate" reality” Evangelium vitae, #2

22. Killing or Letting Die? Locating the PVS/ANH Debate in the Catholic Moral Tradition Context When are the medical means “proportionate” or “disproportionate”? http://www.msnbc.msn.com/id/7268803/

24. Description of the PVS State NOT brain death; nor a “coma” NOT brain death; nor a “coma” Sleep/wake cycles Sleep/wake cycles Some reaction to physical stimuli Some reaction to physical stimuli But no inter-personal interaction But no inter-personal interaction Ir-reversible (Note this point!) Ir-reversible (Note this point!) Need for artificial hydration & nutrition Need for artificial hydration & nutrition

25. Parameters Before a PVS Diagnosis Can Be Made : u NONTRAUMATIC – VERY RARE AFTER 3 MOS. u TRAUMATIC – VERY RARE AFTER 1 YEAR N. B. Sometimes theologians and others confusedly group a PVS case with coma cases. PVS is distinct from a coma diagnosis because in a coma case “recovery” is possible, whereas in PVS “recovery” is not a medical possibility.

26. Subjective Relation to the Patient is Key! Heart Attack Victim Severe Brain Damage 15 years in PVS No Advance Health Care Directive Struggle over removing feeding tube Terri Schiavo before her heart attack Terri with her mother in the nursing home

27. Terri Schiavo’s Medical Diagnosis (Later confirmed by her autopsy) “Over the span of this last decade, Theresa's brain has deteriorated because of the lack of oxygen it suffered at the time of the heart attack. By mid 1996, the CAT scans of her brain showed a severely abnormal structure. At this point, much of her cerebral cortex is simply gone and has been replaced by cerebral spinal fluid. Medicine cannot cure this condition. Unless an act of God, a true miracle, were to recreate her brain, Theresa will always remain in an unconscious, reflexive state, totally dependent upon others to feed her and care for her most private needs.”

28. Dispute over Moral Meaning of the Potential Feeding Tube Removal Removal of the Feeding Tube: Removing an Artificial Block to the Dying Process (i.e. extraordinary means which are stopping the normal dying process)? Removal of the Feeding Tube: Removing an Artificial Block to the Dying Process (i.e. extraordinary means which are stopping the normal dying process)? OR OR Removal of the Feeding Tube: Starving a Person to Death (i.e., Passive Euthanasia)? Removal of the Feeding Tube: Starving a Person to Death (i.e., Passive Euthanasia)? How to Decide? How to Decide?

29. Enter the Magisterium: Whose and What Authority ?

30. Magisterial Teachings on Health Care Allocutions of Pius XII (1939-1958) Allocutions of Pius XII (1939-1958) 1995 John Paul II Encyclical Evangelium Vitae 1995 John Paul II Encyclical Evangelium Vitae 1992/97 Catechism of the Catholic Church 1992/97 Catechism of the Catholic Church US Bishops Ethical & Health Care Directives (various editions) US Bishops Ethical & Health Care Directives (various editions) March 2004 John Paul II Allocution March 2004 John Paul II Allocution November 2004 John Paul II Allocution November 2004 John Paul II Allocution CDF 2007 Responsum on ANH CDF 2007 Responsum on ANH How to weigh & interpret these?? How to weigh & interpret these??

31. Common Misperceptions No text is self-interpreting or self-applying No text is self-interpreting or self-applying All texts are not created equal All texts are not created equal The “latest” text is not necessarily the most authoritative The “latest” text is not necessarily the most authoritative There is no “The Vatican” which exists as a monolithic entity (which office issued it?) There is no “The Vatican” which exists as a monolithic entity (which office issued it?) The language used does not necessarily mean the same as in general idiomatic usage (e.g. “intrinsically disordered”) The language used does not necessarily mean the same as in general idiomatic usage (e.g. “intrinsically disordered”) Each & every pronouncement of the Pope (or lower authorities) is not necessarily infallible. Each & every pronouncement of the Pope (or lower authorities) is not necessarily infallible.

32. 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. … ADDRESS OF JOHN PAUL II TO THE CONGRESS ON "LIFE-SUSTAINING TREATMENTS AND VEGETATIVE STATE: SCIENTIFIC ADVANCES AND ETHICAL DILEMMAS" 20 March 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.

33. So Didn’t’ The Pope Say That We ALWAYS Have to Use a Feeding Tube? “The plants in Terri Schiavo’s room are getting better care than she is.” Fr. Frank Pavone, Priests For Life Is this case really so black and white??

34. Some Key Terminology Medical Act: Medical Act: What constitutes a medical or non-medical act? What constitutes a medical or non-medical act? Possible confusion over labeling a “medical” act as “extraordinary means” Possible confusion over labeling a “medical” act as “extraordinary means” In Principle In Principle Levels of moral norms and principles Levels of moral norms and principles “In principle students should attend every class” “In principle students should attend every class” Recognizes that legitimate exceptions might arise (e.g., illness, emergency, death of a relative, etc.) Recognizes that legitimate exceptions might arise (e.g., illness, emergency, death of a relative, etc.) Proportionate Proportionate For a “proportion” one needs at least 2 terms For a “proportion” one needs at least 2 terms Thus, for any medical means to be called “proportionate” or “disproportionate” means there must be a relation to a concrete, individual subject Thus, for any medical means to be called “proportionate” or “disproportionate” means there must be a relation to a concrete, individual subject And therefore it is impossible to say that always this or that “medical means” could be considered “ordinary and proportionate” And therefore it is impossible to say that always this or that “medical means” could be considered “ordinary and proportionate”

35. 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. … Taking Another Look at ADDRESS OF JOHN PAUL II TO THE CONGRESS ON "LIFE-SUSTAINING TREATMENTS AND VEGETATIVE STATE: SCIENTIFIC ADVANCES AND ETHICAL DILEMMAS" 20 March 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.

36. The Last Papal Address “True compassion, on the contrary, encourages every reasonable effort for the patient's recovery. At the same time, it helps draw the line when it is clear that no further treatment will serve this purpose. The refusal of aggressive treatment is neither a rejection of the patient nor of his or her life. Indeed, the object of the decision on whether to begin or to continue a treatment has nothing to do with the value of the patient's life, but rather with whether such medical intervention is beneficial for the patient. The possible decision either not to start or to halt a treatment will be deemed ethically correct if the treatment is ineffective or obviously disproportionate to the aims of sustaining life or recovering health. Consequently, the decision to forego aggressive treatment is an expression of the respect that is due to the patient at every moment.” Address of John Paul II to the participants in the 19th international conference of the pontifical council for health pastoral care 11 November 2004

37. Change or Continuity? CDF Responsum on ANH Responses To Certain Questions Of The United States Conference Of Catholic Bishops Concerning Artificial Nutrition &Hydration Responses To Certain Questions Of The United States Conference Of Catholic Bishops Concerning Artificial Nutrition &Hydration 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? 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?

38. The Responsum to the 1st Dubium [“Question”] 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 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

39. The Second Dubium 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? 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?

40. & The Second Responsum 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. 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.

41. Level of Magisterial Authority? The Supreme Pontiff Benedict XVI, at the Audience granted to the undersigned Cardinal Prefect of the Congregation for the Doctrine of the Faith, approved these Responses, adopted in the Ordinary Session of the Congregation, and ordered their publication. Rome, from the Offices of the Congregation for the Doctrine of the Faith, August 1, 2007. William Cardinal Levada Prefect The Supreme Pontiff Benedict XVI, at the Audience granted to the undersigned Cardinal Prefect of the Congregation for the Doctrine of the Faith, approved these Responses, adopted in the Ordinary Session of the Congregation, and ordered their publication. Rome, from the Offices of the Congregation for the Doctrine of the Faith, August 1, 2007. William Cardinal Levada Prefect In Forma Communi: A Dicasterial Document In Forma Communi: A Dicasterial Document And NOT a Papal Act And NOT a Papal Act And certainly not “irreformable in se” And certainly not “irreformable in se”

42. And the Attached Commentary?? Different level of extrinsic authority from the Responsum Different level of extrinsic authority from the Responsum A perplexing footnote: “Terminology concerning the different phases and forms of the ‘vegetative state’ continues to be discussed, but this is not important for the moral judgment involved.” A perplexing footnote: “Terminology concerning the different phases and forms of the ‘vegetative state’ continues to be discussed, but this is not important for the moral judgment involved.” “Discussed” but “not important”?? “Discussed” but “not important”?? What might the Catholic moral tradition say? What might the Catholic moral tradition say?

43. Continuing Discussion in the Catholic Tradition: Probabilism Position of St. Alphonsus Liguori Position of St. Alphonsus Liguori In case of practical doubt In case of practical doubt When credible, prudent arguments exist When credible, prudent arguments exist And/or trusted authorities hold a position And/or trusted authorities hold a position One may in good conscience choose the option which has greater “freedom” One may in good conscience choose the option which has greater “freedom” Even if “safer” counter-arguments and/or authorities hold the opposite, and it is more probable (I.e. probabiliorism) Even if “safer” counter-arguments and/or authorities hold the opposite, and it is more probable (I.e. probabiliorism)

44. But when this perishable will have put on the imperishable, and this mortal will have put on immortality, then will come about the saying that is written, Death is swallowed up in victory. Death, Where Is Your Victory? Death, Where Is Your Sting? 1 Corinthians 15:54-55

45. Catholic Teaching: True or False? #1: Medical treatment must always be continued, as long as it provides some medical benefit to the patient. FALSE #1: Medical treatment must always be continued, as long as it provides some medical benefit to the patient. FALSE #2: Some medical procedures or drugs are always morally required (such as feeding tubes). FALSE #2: Some medical procedures or drugs are always morally required (such as feeding tubes). FALSE #3: Pain medication which would hasten death is not permitted. FALSE #3: Pain medication which would hasten death is not permitted. FALSE #4: Living wills in which one elects not to pursue aggressive treatment are not permitted. FALSE #4: Living wills in which one elects not to pursue aggressive treatment are not permitted. FALSE #5: The Church is opposed to the notion of “death with dignity.” FALSE #5: The Church is opposed to the notion of “death with dignity.” FALSE #6: In cases of terminal illness the Church opposes hastening or ending a life to end that pain TRUE #6: In cases of terminal illness the Church opposes hastening or ending a life to end that pain TRUE

46. A Helpful Tradition… In fide, unitas: in dubiis, libertas; in omnibus, caritas In fide, unitas: in dubiis, libertas; in omnibus, caritas "In faith, unity; in doubt, liberty; in all things, charity." "In faith, unity; in doubt, liberty; in all things, charity." Attributed to St. Augustine, this is an important principle of Christian discernment: unity in faith is important, but in cases of doubt a plurality of opinions and practices should be allowed, and the over-riding principle must always be charity towards each other. Attributed to St. Augustine, this is an important principle of Christian discernment: unity in faith is important, but in cases of doubt a plurality of opinions and practices should be allowed, and the over-riding principle must always be charity towards each other.