Medical Care at the End of Life: A Catholic Perspective

Chapter 1. Ordinary and Extraordinary Means

This page intentionally left blank INTRODUCTION FOR the past thirty years I have written about medical ethics and taught the subject to physicians, nurses, social workers, hospital chaplains, undergraduates, and graduate students. During this time I have been active in American hospitals and nursing homes, helping patients and their families deal with the difficult and often painful issues regarding medical treatment at the end of life. As I have worked on hospital ethics committees, designed hospital and nursing home policy, and taken part in ethics consultations, I have also helped my own friends, colleagues, and family members work their way through these issues. In this book I write about what I have learned. My aim is to provide patients, their families, hospital chaplains , and the entire health care community with a useful resource for thinking about decisions that so many people, at some point in life, must face. This, then, is a practical guidebook that describes in detail the American ethics and law about forgoing treatment. It draws on Roman Catholic medical ethics, since much of what has become American policy in the area was taken from Catholic sources, and it engages certain questions that are currently debated within Catholic medical ethics. But it is not intended only or even primarily for those interested in Catholic issues. It is a book about the ethics of end-of-life care in America. Two recent events have focused attention, both within and without the field of Catholic bioethics, on this critical issue. In March 2004 Pope John Paul II delivered an allocution, also known as a – ix – x Introduction formal speech, concerning nutrition and hydration (John Paul II 2004). And then, more recently, came the case of Theresa Marie Schiavo, the Florida woman whose feeding tube was removed after years of political and legal dispute. I will discuss both of these events, given the profound implications they have had within Catholic bioethics and on the American medical and political landscape. There are eight chapters in this book. The first five develop in detail the bases for what I call the ‘‘American consensus’’ on forgoing treatment. Chapter 1 introduces the three pillars, or bases, for the American approach to this area and presents the first of them: the widespread agreement that some life-sustaining treatment is ethically optional and may be withheld. Chapter 2 details the important distinction between actively killing dying people and allowing them to die, a distinction I call the second pillar. Chapters 3, 4, and 5 analyze in detail the third pillar, the important legal and ethical issues of who decides and how the decision is made, including issues concerning competent and incompetent patients as well as advance directives (living wills and durable powers of attorney for health care). I introduce the Schiavo legal case in this context. Chapter 6 is about feeding tubes. I discuss and reject the proposals of some who, by requiring nutrition and hydration for permanently unconscious patients, would undermine the claim that treatment is optional if its burdens outweigh its benefits. Here I again note Schiavo and discuss at some length the 2004 papal allocution . In chapter 7 I reject arguments by those who would support the practice of euthanasia and physician-assisted suicide and would reject the claim that there is an important difference between killing and allowing to die. And in chapter 8, on medical futility, I confront claims by those who would reduce the authority of patients to make decisions about their treatment. This book is not meant to be an exhaustive treatment of end-oflife matters. It is intended to highlight what I believe to be the most important issues at stake—issues that require clear thinking and some understanding of medical ethics and relevant legal cases. I can only hope that readers of this book will gain some useful knowledge, and some degree of comfort, from my efforts. ABBREVIATIONS CPR cardiopulmonary resuscitation DNR do not resuscitate DPA durable power of attorney DRG diagnosis related group ER emergency room HMO health management organization ICU intensive care unit IRB Institutional Review Board PAS physician-assisted suicide PDE principle of double effect PET positron emission topography PSDA Patient Self-Determination Act PVS persistent vegetative state UDDA Uniform Definition of Death Act USCC United States Catholic Conference – xi – This page intentionally left blank j Chapter 1 i Ordinary and...