2. Using or forgoing life-sustaining treatments (LST)

3. Distinctions Forgoing life-sustaining treatment (withholding or withdrawing treatment) versus Euthanasia and assisted suicide

4. Theology of Death and Dying Catholic Health Association: “In the Roman Catholic tradition, human life is regarded as sacred from the moment of conception until natural death because it is created and given to us by God. For this reason, we have a duty to protect and preserve our lives. Yet this duty is not absolutely binding under all circumstances because we know that our ultimate end lies in eternal life with God. (italics added)

5. Theology of Death and Dying “Pope John Paul II in Evangelium Vitae observes that “it is precisely this supernatural calling which highlights the relative character of each individual’s earthly life. After all, life on earth is not an ‘ultimate’ but a ‘penultimate’ reality.” “In light of this belief, it has been widely accepted among Catholic moralists from the 16 th century onward that one need only employ ‘ordinary’ means of preserving life, but not those deemed ‘extraordinary…’”

6. Principles for making decisions about LST in the Catholic Tradition: Historical Ordinary/extraordinary treatment distinction Principle: “Ordinary” treatments should be used but permissible to forgo treatments which are “extraordinary” in character” Problems with distinction and principle

7. Principles for making decisions about LST Refinement in Declaration on Euthanasia (1980): proportionate and disproportionate means Proportionate/disproportionate means understood in terms of benefits and burdens

8. Principles for making decisions about LST: Benefits/Burdens Ethical and Religious Directives for Catholic Health Care Services (ERD) 56. A person has a moral obligation to use ordinary or proportionate means of preserving his or her life. continued…

9. Principles for Making Decisions about LST: Benefits/Burdens ERD no. 56 Proportionate means are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community.

10. Principles for Making Decisions about LST: Benefits & Burdens ERD no. 57 A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patient’s judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.

11. Benefits and Burdens Principle Ordinary treatment = proportionate to results = reasonable hope of benefit and no excessive burden Extraordinary treatment = disproportionate to results = no reasonable hope of benefit or excessive burden

12. Benefits and Burdens Principle What are benefits? Some examples: Treatment will bring about a cure or at least improve the patient’s health status Treatment will relieve pain Treatment will increase the patient’s mobility Treatment will restore consciousness Treatment will improve patient’s ability to communicate with others

13. Benefits and Burdens Principle What are burdens? Some examples: Treatment causes pain or substantial discomfort Treatment entails psychological burdens, e.g., depression Difficulty getting access to treatment (e.g., driving distance) Patient has to be restrained to tolerate the treatment Substantial cost for patient and/or family

14. Benefits and Burdens Principle Morally permissible to forgo (withhold or withdraw) a life-sustaining treatment when… No real hope of benefit to the patient (useless, futile) OR “Excessively burdensome” (the burdens of the treatment outweigh its benefits) Who judges benefits and burdens: the patient (or his/her proxy decision maker)

15. Benefits and Burdens Principle In practice at bedside, has replaced the ordinary/extraordinary distinction Difference from ordinary/extraordinary treatment distinction * No treatment automatically used/forgone * Decisions made on a case-by-case basis

16. Clarifications Withholding vs. withdrawing treatments Ethically and legally, just as permissible to withdraw a treatment as never to start it If unsure if a treatment will benefit a patient, a time-trial is recommended.

17. Principles for Surrogate/Proxy Decision Making Principle of Substituted Judgment (Gold standard): proxy attempts to reach decision that incapacitated patient would make, based on: Patient’s written or oral directives Knowledge of patient’s beliefs, values, preferences, life-long behavior patterns How would the patient judge the benefits and burdens of treatment?

18. Principles for Proxy decision making Best Interests Standard: proxy makes decision seeking to implement what is in patient’s best interests by reference to objective, societally shared criteria Choosing as a reasonable person in the patient’s circumstances would choose How would a reasonable person judge the benefits and burdens in this case?