Bioethics: What constitutes 'extraordinary means' of care?

It's hard not to think about end-of-life issues these days. Assisted-suicide legislation is popping up around the country. Euthanasia is becoming the new cause celebre among Hollywood's elite. And in Florida the heart-wrenching battle over whether to withdraw nutrition and hydration from Terri Schiavo, the brain-damaged woman said to be in a "persistent vegetative state," lately is being played out in courtrooms, Congress and news headlines day after day.

Many people -- including many Catholics -- are beginning to look favorably on things like assisted suicide in part because they often do not clearly understand the Catholic Church's compassionate teaching with regard to disabled or terminally ill patients. The Church allows patients to reject "extraordinary means" of medical treatment and to accept palliative care in order to alleviate all of their pain, even if it might hasten death.

A pain myth

"The Catholic Church has a very clear position that death doesn't have to be prolonged," said Vincentian Father Richard Benson, chairman of moral theology and academic dean at St. John's Seminary in Camarillo, Calif. "It's a myth that the Catholic Church wants people to be in pain."

Father Benson told Our Sunday Visitor that euthanasia and assisted suicide are about "killing the person rather than killing the disease." The Catholic position, he explained, is to allow people to die "as God would have them die."

Part of the problem in this debate stems from confusion over what is an "extraordinary" measure. Does that mean pulling the plug? Does it mean removing a feeding tube? And what about suffering? When is it okay to say that you want the pain and suffering to end?

"People have to realize that even the language 'extraordinary measures' was invented by Catholic theologians in the 16th century. Catholics have been doing bioethics for centuries," said Franciscan Brother Daniel Sulmasy, a medical doctor and director of ethics for St. Vincent's Hospital in Manhattan and New York Medical College. "We have an ordinary obligation to care for our bodies but under certain circumstances that obligation can become extraordinary and that means morally optional."

The key, Brother Sulmasy explained, is that every treatment must be put into context. If a terminally ill patient develops pneumonia as a complication of cancer and it looks like he is going to die within the next few days, then even a simple course of antibiotics could be considered extraordinary.

On the other hand, if an otherwise healthy patient comes into the hospital with an abscess that requires surgery and the use of a ventilator, the ventilator -- which can be costly and burdensome -- is not extraordinary because the benefits outweigh the burdens.

Middle of the road

"The Church's way has always been this sort of sane, Catholic, middle-of-the-road way. Because we have an ordinary obligation to respect our bodies as a gift from God, in most circumstances we have a duty to try to take health care, but we don't have to go to absolute extremes and keep ourselves going even when it's simply prolonging the dying process or is associated with grave suffering," Brother Sulmasy told OSV. "On the other hand, that obligation means we can never kill ourselves or kill another person in order to put them out of their misery."

Treatment is considered "extraordinary" if it is determined to be futile, meaning that it is either not going to work to keep the person alive or to reverse the course of the disease, or if the burdens of that treatment are disproportionate to the benefits.

Then comes the more complex issue of nutrition and hydration. Just last year, Pope John Paul II said that nutrition and hydration are part of basic health care treatment that should be afforded to all patients, including those in a persistent vegetative state (see sidebar). Brother Sulmasy said the Pope's statement did not change anything in terms of Catholic directives.

"There should be a presumption in favor of assisted-hydration and nutrition. I think the most important thing we can take from the papal statement is that the Pope is serious that it's a presumption in favor, not a presumption against it," he explained, adding that there are certain circumstances under which even the nutrition and hydration requirement becomes "rebuttable."

For example, terminal cancer patients who stop eating are not required to have feeding tubes inserted.

Palliative care

Finally, in the midst of the debate is the issue of palliative care -- how to keep patients comfortable and pain-free until death. The Church encourages the use of palliative care and provides it through its many hospitals and hospices around the country. A key portion of Church teaching on palliative care is something known as "double effect," which is credited to St. Thomas Aquinas. When applied to end-of-life care, it means that a patient can receive pain treatment even if that treatment could hasten death.

"This has wide-spread application in Church teaching," said Brother Sulmasy. "Euthanasia is aiming to make a person dead in order to relieve her suffering. What we are talking about is aiming to relieve a patient's suffering foreseeing the possibility that her death might be hastened. There's a crucial moral distinction between those two."

The popes on end-of-life issues

Catholic teaching on the use of ordinary versus extraordinary measures dates to the 16th century. Here are some recent papal statements on end-of-life issues from extraordinary means, to pain control, to euthanasia:

"Normally one is held to use only ordinary means . . . that is to say, means that do not involve any grave burden for oneself or another. A stricter obligation would be too burdensome for most people 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." -- Pope Pius XII, 1957

"To sum up, you ask us: 'Is the suppression of pain and consciousness by means of narcotics (when it is demanded by a medical indication) permitted, by religion and morality, to the patient and the doctor (even at the approach of death and when one foresees that the administration of narcotics will shorten life)?' One must reply, 'If there exist no other means and if, in the given circumstances, it does not prevent the fulfillment of other religious and moral duties -- Yes.'" -- Pope Pius XII, 1957

"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 . . . Death by starvation or dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission." -- Pope John Paul II, 2004