Artificial Nutrition and Hydration and the Permanently Unconscious Patient: The Catholic Debate

4. A History of Ordinary and Extraordinary Means

฀ 53 4 A฀History฀of฀Ordinary฀and฀฀ Extraordinary฀Means Donald฀E.฀Henke The฀death฀of฀Terri฀Schiavo฀in฀Florida฀on฀March฀31,฀2005,฀brought฀into฀high฀relief ฀many฀of฀the฀central฀questions฀concerning฀the฀care฀and฀treatment฀of฀patients฀ in฀the฀persistent฀vegetative฀state฀(PVS).฀At฀the฀center฀of฀the฀Catholic฀discussion ฀of฀this฀contentious฀issue฀has฀been฀whether฀the฀provision฀of฀food฀and฀water฀ is฀an฀extraordinary฀means฀of฀conserving฀life฀when฀a฀patient฀no฀longer฀has฀any฀ measurable฀cognitive-affective฀abilities.฀Although฀my฀own฀work฀on฀the฀topic฀of฀ artificially฀assisted฀hydration฀and฀nutrition฀(AAHN)฀is฀involved฀with฀the฀question ฀of฀whether฀such฀patients฀are฀indeed฀incapable฀of฀awareness฀of฀themselves฀ and฀others,฀that฀issue฀is฀not฀addressed฀here.1 ฀This฀article฀will฀consider฀the฀topic฀ of฀ordinary฀and฀extraordinary฀means฀as฀the฀background฀for฀the฀larger฀discussion฀ within฀the฀Church฀over฀the฀appropriate฀care฀of฀PVS฀patients.฀After฀a฀survey฀of฀ key฀historical฀ideas฀in฀the฀development฀of฀this฀distinction,฀I฀conclude฀with฀some฀ comments฀on฀how฀the฀distinction฀between฀ordinary฀and฀extraordinary฀treatment฀ helped฀the฀bishops฀and฀the฀Church’s฀magisterium฀to฀arrive฀at฀the฀conclusion฀that฀ the฀provision฀of฀food฀and฀water฀is฀morally฀obligatory,฀in฀most฀cases,฀for฀those฀ who฀are฀in฀the฀PVS. Ordinary฀and฀Extraordinary฀Means฀of฀Preserving฀Life Catholic฀teaching฀regarding฀human฀life฀starts฀from฀more฀general฀principles฀that฀ delineate฀the฀ultimate฀nature฀of฀the฀human฀person,฀and฀then฀moves฀to฀more฀ 54฀ ฀ ฀฀฀฀฀ specific฀principles฀aimed฀at฀safeguarding฀human฀dignity฀and฀caring฀for฀human฀ life฀within฀the฀bounds฀of฀health฀care.฀Because฀human฀life฀is฀a฀precious฀gift฀of฀ God,฀the฀positive฀requirements฀incumbent฀upon฀the฀human฀person฀demand฀that฀ he฀assume฀a฀reasonable฀degree฀of฀care฀for฀his฀life;฀however,฀because฀human฀life฀is฀ not฀an฀absolute฀good฀to฀be฀maintained฀at฀all฀costs,฀there฀are฀equally฀important฀ limits฀to฀this฀duty.฀The฀efforts฀of฀the฀Church฀throughout฀its฀history฀to฀outline฀ the฀duty฀and฀limits฀of฀caring฀for฀human฀life฀has฀resulted฀in฀a฀solid฀moral฀tradition ฀that฀advocates฀the฀use฀of฀all฀ordinary฀means฀to฀preserve฀life,฀along฀with฀a฀ right฀to฀forgo฀any฀extraordinary฀means฀to฀preserve฀life. The฀vitally฀important฀address฀by฀Pope฀Pius฀XII฀in฀1957฀to฀a฀group฀of฀Catholic ฀physicians฀and฀anesthesiologists฀gave฀a฀succinct฀statement฀of฀the฀Church’s฀ position฀regarding฀the฀ordinary฀and฀extraordinary฀means฀of฀conserving฀life.฀The฀ Pope฀stated: Normally฀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.฀On฀the฀other฀hand,฀one฀is฀not฀forbidden฀to฀take฀more฀ than฀the฀strictly฀necessary฀steps฀to฀preserve฀life฀and฀health,฀as฀long฀as฀he฀does฀not฀ fail฀in฀some฀more฀serious฀duty.2 In฀1958,฀the฀theological฀study฀by฀Daniel฀Cronin฀constructed฀a฀comprehensive ฀analysis฀of฀the฀Church’s฀moral฀tradition฀pertaining฀to฀the฀ordinary฀and฀extraordinary ฀means฀of฀conserving฀human฀life.3 ฀The฀treatment฀of฀this฀subject฀in฀ my฀article฀will฀present฀a฀representative฀selection฀of฀the฀theologians฀who฀clarified฀ the฀major฀tenets฀of฀the฀obligations฀and฀limits฀correlative฀to฀the฀preservation฀of฀ life.฀The฀brief฀examination฀of฀the฀principles฀governing฀the฀care฀of฀human฀life฀ will฀provide฀both฀a฀glimpse฀into฀the฀course฀of฀historical฀development฀of฀the฀ Catholic฀moral฀tradition฀and฀an฀important฀reference฀point฀for฀the฀arguments฀ used฀to฀promote฀the฀provision฀or฀withholding฀of฀AAHN฀to฀the฀PVS฀patient,฀ which฀will฀be฀discussed฀later. Historical฀Roots฀and฀Use฀of฀the฀Terms In฀the฀course฀of฀his฀research,฀Cronin฀discovered฀that฀the฀seeds฀upon฀which฀the฀ ordinary฀and฀extraordinary฀means฀of฀preserving฀life฀would฀later฀grow฀were฀to฀be฀ found฀in฀the฀treatises฀of฀St.฀Thomas฀Aquinas,฀particularly฀in฀his฀treatment฀of฀ suicide฀and฀bodily฀mutilation.4 ฀Of฀significant฀value฀for฀later฀theologians,฀who฀ more฀thoroughly฀addressed฀the฀demands฀and฀limits฀of฀a฀human฀person’s฀responsibility ฀to฀preserve฀his฀life,฀was฀this฀statement฀of฀St.฀Thomas:฀“A฀man฀has฀the฀ obligation฀to฀sustain฀his฀body,฀otherwise฀he฀would฀be฀a฀killer฀of฀himself฀.฀.฀.฀by฀ precept,฀therefore,฀he฀is฀bound฀to฀nourish฀his฀body฀and฀likewise,฀we฀are...