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

14. End-of-Life Care Revisited

฀ 187 14 End-of-Life฀Care฀Revisited฀ Daniel฀P.฀Sulmasy,฀OFM A฀number฀of฀claims฀made฀in฀recent฀discussions฀about฀Catholic฀teaching฀and฀the฀ use฀of฀life-sustaining฀treatments฀raise฀important฀and฀very฀serious฀theological,฀ philosophical,฀and฀medical฀questions฀that฀have฀received฀almost฀no฀direct฀attention ฀or฀examination. Some฀recent฀forms฀of฀argument฀seem฀to฀deviate฀from฀established,฀traditional฀ forms฀of฀Catholic฀argument.฀Yet฀the฀nature฀and฀extent฀of฀these฀deviations฀from฀ tradition฀have฀not฀been฀apparent฀to฀most฀commentators.฀Some฀recent฀claims฀ have฀been฀based฀upon฀oversimplified฀understandings฀of฀clinical฀and฀economic฀ reality.฀Still฀other฀claims฀appear฀to฀be฀based฀upon฀novel฀philosophies฀of฀medicine ฀that฀have฀not฀been฀made฀explicit.฀In฀this฀brief฀article,฀I฀make฀some฀of฀these฀ questions฀explicit฀for฀the฀sake฀of฀furthering฀honest฀discussion฀of฀the฀ethics฀of฀ life-sustaining฀treatments฀among฀the฀faithful. Intending฀Death?฀ Claim฀1:฀When฀one฀discontinues฀the฀use฀of฀a฀feeding฀tube฀in฀a฀patient฀who฀is฀in฀a฀persistent฀vegetative ฀state฀(perhaps฀better฀termed฀“post-coma฀unresponsiveness”),฀and฀that฀person฀has฀left฀no฀advance฀ instructions฀asking฀that฀this฀be฀done฀for฀a฀morally฀legitimate฀reason,฀then฀one฀must฀be฀intending฀that฀ person’s฀death฀as฀a฀means฀of฀relieving฀his฀or฀her฀suffering฀and฀therefore฀committing฀euthanasia. This฀form฀of฀argument฀has฀been฀very฀prominent.1 ฀However,฀there฀is฀an฀underlying ,฀unrecognized฀premise฀at฀the฀argument’s฀heart—that฀the฀proper฀moral฀ principle฀by฀which฀to฀analyze฀the฀act฀of฀withdrawing฀a฀life-sustaining฀treatment฀ is฀the฀rule฀of฀double฀effect.฀This฀rule฀has฀assumed฀an฀unprecedented฀prominence ฀in฀Catholic฀circles฀in฀recent฀years,฀due฀to฀the฀influence฀of฀what฀has฀been฀ called฀the฀“New฀Natural฀Law฀Theory.”฀According฀to฀this฀theory,฀which฀effectively ฀removes฀ontological฀considerations฀from฀natural-law฀thinking,฀everyone฀ must฀act฀for฀one฀of฀a฀small฀number฀of฀reasons฀called฀“basic฀goods,”฀and฀one฀ may฀never฀act฀directly฀against฀one฀of฀these฀basic฀goods.฀These฀theorists฀recognize ฀that,฀in฀real฀life,฀however,฀one฀is฀constantly฀facing฀choices฀in฀which฀one฀good฀ must฀be฀sacrificed฀so฀that฀another฀can฀be฀realized. According฀to฀this฀theory,฀one฀may฀tolerate฀an฀act฀that฀goes฀against฀a฀basic฀ good฀(e.g.,฀undermines฀respect฀for฀life฀or฀marriage)฀only฀if฀this฀bad฀result฀is฀an฀ indirect,฀unintended฀side฀effect฀of฀acting฀to฀promote฀another฀basic฀good.฀That฀ is฀to฀say,฀the฀rule฀of฀double฀effect฀applies฀in฀all฀these฀situations.฀Therefore,฀in฀a฀ feeding฀tube฀case,฀the฀New฀Natural฀Law฀Theory฀directs฀the฀patient’s฀loved฀ones฀ to฀ask฀themselves,฀“What฀good฀am฀I฀trying฀to฀accomplish฀here?”฀If฀they฀answer,฀ “Relieving฀the฀patient’s฀suffering,”฀they฀will฀violate฀the฀rule฀of฀double฀effect.฀ Since฀the฀feeding฀tube฀itself฀does฀not฀appear฀to฀be฀doing฀any฀harm,฀the฀only฀ way฀to฀relieve฀the฀suffering฀of฀the฀patient฀is฀by฀way฀of฀making฀the฀patient฀dead.฀ Therefore,฀it฀is฀concluded฀that฀the฀act฀is฀morally฀impermissible. However,฀the฀story฀is฀complicated฀because฀commentators฀who฀would฀require฀ feeding฀tubes฀for฀patients฀suffering฀from฀post-coma฀unresponsiveness฀are฀not฀ the฀only฀ones฀who฀use฀the฀rule฀of฀double฀effect฀in฀this฀situation.฀Some฀who฀ argue฀that฀it฀is฀permissible฀to฀withdraw฀feeding฀tubes฀from฀such฀patients฀also฀ invoke฀the฀rule฀of฀double฀effect฀in฀doing฀so.฀To฀make฀the฀argument฀work,฀however ,฀they฀are฀forced฀to฀conclude฀that฀the฀treatment฀is฀of฀“no฀benefit,”฀so฀that฀ even฀the฀most฀minimal฀burdens฀caused฀by฀the฀feeding฀tube฀can฀be฀considered฀ disproportionate.฀Of฀note,฀this฀seems฀to฀entail฀the฀judgment฀that฀life฀itself฀is฀ not฀a฀good,฀since฀the฀effect฀of฀the฀treatment฀(maintaining฀life)฀is฀judged฀to฀be฀ of฀no฀benefit.฀Justifiably,฀this฀has฀upset฀orthodox฀Catholic฀sensibilities,฀since฀it฀ seems฀to฀denigrate฀the฀value฀of฀human฀life. I฀argue,฀however,฀that฀both฀sides฀of฀the฀debate฀are฀mistaken฀because฀they฀have฀ framed฀the฀problem฀using฀the฀wrong฀principle.฀The฀Catholic฀moral฀tradition฀ has฀for฀several฀centuries฀relied฀upon฀the฀casuistry฀of฀withholding฀and฀withdrawing ฀extraordinary฀means฀of฀care฀as฀the฀proper฀framework฀for฀analyzing฀such฀ cases,฀not฀the฀rule฀of฀double฀effect.฀The฀moral฀theology฀of฀forgoing฀extraordinary ฀means฀of฀care฀was฀developed฀independently฀of฀the฀rule฀of฀double฀effect฀ and฀this฀rule฀was฀never฀invoked฀in฀its฀development฀or฀justification.฀Instead,฀the฀ 188฀ ฀ ฀฀฀ traditional฀understanding฀of฀forgoing฀extraordinary฀means฀has฀been฀based฀upon฀ the฀principles฀of฀“physical฀and฀moral฀impossibility.” These฀principles฀are...