Bioethical Magisterium on Normal Treatment and Ordinary Care

"Extraordinary means" (disproportionate means) are not obligatory.

• Extraordinary or disproportionate means are those treatments, medications, or procedures that cause excessive burden to the patient or offer no reasonable hope of benefit of remedy or cure of the condition or disease.
  
• Even though the patient is not obliged to use the treatment, medication, or procedure, he is not precluded from using it even though it is extraordinary. As stated in the "Declaration on Euthanasia,"

"If there are no other sufficient remedies, it is permitted, with the patient's consent, to have recourse to the means provided by the most advanced medical techniques, even if these means are still at the experimental stage and are not without a certain risk. By accepting them, the patient can even show generosity in the service of humanity."

• If the patient, either personally or through a designated proxy, elects to use the treatment, the presumption is that it should be given. Here prudent, expert medical assessment can greatly serve a just outcome. The "Declaration on Euthanasia" clarifies this point with regard to the patient's wishes:

"It is also permitted, with the patient's consent, to interrupt these means [provided by the most advanced medical techniques], where the results fall short of expectations. But for such a decision to be made, account will have to be taken of the reasonable wishes of the patient and the patient's family, as also of the advice of the doctors who are specially competent in the matter. The latter may in particular judge that the investment in instruments and personnel is disproportionate to the results foreseen; they may also judge that the techniques applied impose on the patient strain or suffering out of proportion with the benefits which he or she may gain from such techniques." (Emphasis added)

• Once a decision is made not to use an extraordinary means, all ordinary treatment must, nevertheless, be initiated or continued.
  
• To be clear, even if the illness [6,7,8,9,10] has no remedy, the patient is not untreatable, and normal treatment directed to the care of the patient which is not futile must be given. (See 1.3.a, above)
  
• A given treatment of the condition or disease can never be terminated or withheld with the intention of killing the patient.
  
• Even otherwise extraordinary means become obligatory if they will allow time to be reconciled with God and to receive the sacraments of the Church. The question here is a pastoral one which has a moral dimension. Will life-sustaining treatment permit the opportunity for reception of the sacraments, or perhaps, reconciliation between family members under appropriate circumstances? If so, the treatment should be administered long enough to provide that opportunity.

Normal Treatment and Care

The concept of normal treatment or care has been mentioned several times in this doctrinal presentation. In some cases the Church has made a judgment indicating what constitutes normal treatment. This concept does not appear to be well-developed or even recognized in the analyses of many theologians, yet it possesses some distinction in the bioethical magisterium. Some clarification can be made on the issue. Euthanasia is not only any action that is intended to bring about death. The crime includes any action or omission which "of itself ... causes death, in order that all suffering may in this way be eliminated."

Similarly, in the theological tradition there is that type of action or omission which cannot be classified, strictly speaking, as either (1) intended to bring about death or (2) extraordinary or disproportionate to the expected outcome. In other words, according to the moralists, some treatment or care is due in certain circumstances, and, morally speaking, cannot be terminated.

Examined and explained from the viewpoint of this theological tradition, the Declaration recognizes that there are certain of these cases which, according to the type of care involved and the object of the action itself, fall into the definition of euthanasia. In light of recent statements of the magisterium, normal or ordinary treatment and care of the patient are to be distinguished from the category of treatments of disease or condition which can be extraordinary. In the case of these acts of care and treatment, the burden and futility have to be interpreted in reference to the comfort and life-sustaining effects they afford to the patient and not to the cure, remedy, or reversal of the disease or condition affecting the patient. Medically assisted feeding and hydration, sometimes referred to as artificial nutrition and hydration, has gained special recognition in that regard.

Medically assisted feeding and hydration are part of the normal treatment due a patient.

Concerning the concept of normal care or means judged ordinary, according to John Paul II,

"A great teaching effort is needed to clarify the substantive moral difference between discontinuing medical procedures that may be burdensome, dangerous, or disproportionate to the expected outcome--what the Catechism of the Catholic Church calls 'the refusal of "over-zealous" treatment'" (2278; cf Evangelium vitae, 65)--and taking away the ordinary means of preserving life, such as feeding, hydration, and normal medical care.

The Charter for Health Care Workers, as a document which promotes magisterial teaching applies the principle this way: "The administration of food and liquids, even when medically delivered, is part of the normal treatment always due to the patient when this is not burdensome for him; their undue suspension could be real and properly so-called euthanasia."

Life itself, even for the dying, is not to be considered a burden. In determining whether or not such a burden exists as to merit withholding or withdrawing food and water, one is to look at the immediate burdens imposed by the treatment, not the "quality of life" of the patient.

It is not permissible to discriminate among patients on the basis of their condition insofar as justice and their fundamental rights are concerned.

In the case of feeding and hydration, the moral assessment focuses on the term of reference identified as ordinary care or normal treatment of the patient. The factual medical question to be answered for the moral evaluation is: Does feeding and hydration sustain the life of the patient in the particular case? Or, on the other hand, is the food and water, however they are supplied, being rejected by the body or not being adequately assimilated? In other words, is it futile? If indeed, the person can assimilate the food and water, the question may arise whether the medical means of assisting in feeding and hydration constitute too great a burden as to be required in a particular case.

Explanatory Note: Analyzing treatment options this way is true to the magisterium and keeps the prudential assessment focused on the burden of the means of administration. It avoids slipping into the immoral attempt to estimate the value of an individual human life, no matter how severely disabled he or she may be or whatever condition or pathology she or he may have. It avoids, as well, the implicit act of judging the futility or burden of the normal treatment by a misguided reference to the treatment of the condition or disease affecting the patient, when, in fact, this normal treatment is directed to caring for and sustaining the life of the patient. The omission of this normal care or treatment when it is life-sustaining and when the means of providing food and water is not excessively burdensome is an injustice which by its nature will cause the death of the patient. The distinction between normal treatment and other types of treatments whose object is a remedy to the disease or condition affecting the patient, with their different objects, help preserve the "substantive moral difference" the Holy Father references in 4.1, above.

In the case of the patient who cannot make decisions for himself, as is the case of those persons considered to be unconscious or in a so-called "persistent vegetative state," food and water are morally required as normal treatment due to all persons in any condition, no matter how disabled, as long as prudent means for providing them are available. The NCCB Pro-life Committee statement has interpreted the magisterium in just this way. These patients must not be "routinely classified as `terminal' or as prime candidates for the discontinuance of even minimal means of life support."

The NCCB Pro-life Committee statement makes some recommendations for questions which are helpful for assessing the burden of the treatment and avoiding the unjust omission of treatment to unconscious patients:

On a practical level, those seeking to make good decisions might assure themselves of their own intentions by asking: Does my decision aim at relieving the patient of a particularly grave burden imposed by medically assisted nutrition and hydration? Or does it aim to avoid the total burden of caring for the patient? If so, does it achieve this aim by deliberately bringing about his or her death?

Endnotes

1 The Declaration on Euthanasia states:

In order to facilitate the application of these general principles, the following clarifications can be added:

If there are no other sufficient remedies, it is permitted, with the patient's consent, to have recourse to the means provided by the most advanced medical techniques, even if these means are still at the experimental stage and are not without a certain risk. By accepting them, the patient can even show generosity in the service of humanity.

It is also permitted, with the patient's consent, to interrupt these means, where the results fall short of expectations. But for such a decision to be made, account will have to be taken of the reasonable wishes of the patient and the patient's family, as also of the advice of the doctors who are specially competent in the matter. The latter may in particular judge that the investment in instruments and personnel is disproportionate to the results foreseen; they may also judge that the techniques applied impose on the patient strain or suffering out of proportion with the benefits which he or she may gain from such techniques.

It is also permissible to make do with the normal means that medicine can offer. Therefore one cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community.

When inevitable death is imminent in spite of the means used, it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted. In such circumstances the doctor has no reason to reproach himself with failing to help the person in danger.

See, Charter for Health Care Workers, Pontifical Commission for Pastoral Care to Health Care Workers (May 1994) #65 ; Cong. Doct. Faith, "Declaration on Euthanasia," May 5, 1980 in AAS 72 (1980) pp. 549-550.

2 .The importance of this distinction is manifested in Evangelium vitae, 78:

"Threats which are no less serious hang over the incurably ill and the dying. In a social and cultural context which makes it more difficult to face and accept suffering, the temptation becomes all the greater to resolve the problem of suffering by eliminating it at the root, by hastening death so that it occurs at the moment considered most suitable. ...

"Various considerations usually contribute to such a decision, all of which converge in the same terrible outcome. ...

On a more general level, there exists in contemporary culture a certain Promethean attitude which leads people to think that they can control life and death by taking the decisions about them into their own hands. What really happens in this case is that the individual is overcome and crushed by a death deprived of any prospect of meaning or hope. We see a tragic expression of all this in the spread of euthanasia ­ disguised and surreptitious, or practiced openly and even legally. As well as for reasons of a misguided pity at the sight of the patient's suffering, euthanasia is sometimes justified by the utilitarian motive of avoiding costs which bring no return and which weigh heavily on society. Thus it is proposed to eliminate malformed babies, the severely handicapped, the disabled, the elderly, especially when they are not self-sufficient, and the terminally ill.

3. "Even when it cannot cure, science can and should treat and assist the sick person" (John Paul II, To the participants at a study course on "human preleukemias," Nov. 15, 1985, in Insegnamenti VIII/2, p. 1265, n. 5. Cf. John Paul II, To two work groups set up by the Pontifical Academy of Sciences, Oct. 21, 1985, in Insegnamenti VII/2, p. 1082, n. 4).

4. John Paul II, "The Mystery of Life and Death: Address to Pontifical Academy of Sciences," Origins (Dec. 5, 1985).

5. The Charter for Health Care Workers, citing the "Declaration on Euthanasia," states:

Contemporary medicine, in fact, has at its disposal methods which artificially delay death, without any real benefit to the patient. It is merely keeping one alive or prolonging life for a time, at the cost of further, severe suffering. This is the so-called "therapeutic tyranny," which consists "in the use of methods which are particularly exhausting and painful for the patient, condemning him in fact to an artificially prolonged agony."

This is contrary to the dignity of the dying person and to the moral obligation of accepting death and allowing it at last to take its course. "Death is an inevitable fact of human life": it cannot be uselessly delayed, fleeing from it by every means.

Charter, #119. Cf. John Paul II, To the participants at the International Congress on Assistance to the Dying, in Oss. Rom March 18, 1992, n. 4. Cf. John Paul II, Encyclical Evangelium vitae, March 25, 1995, n. 65. John Paul II, To two work groups set up by the Pontifical Academy of Sciences, Oct. 21, 1985, in Insegnamenti VIII/2, p. 1082, n. 5. "From this point of view, the use of therapeutic means can sometimes raise problems": Cong. Doct. Faith, Declaration on Euthanasia, May 5, 1980, in AAS 72 (1980) p. 549.

6. John Paul II, Ad limina address to Bishops of California and Hawaii, Oct. 2, 1998, (AAS_____).

7. See the Charter for Health Care Workers, #120, which states:

Aware that he is "neither the lord of life nor the conqueror of death," the health care worker, in evaluating means, "should make appropriate choices, that is, relate to the patient and be guided by his real condition."

Here he will apply the principle ­ already stated ­ of "appropriate medical treatment," which can be specified thus: "When inevitable death is imminent, despite the means used, it is lawful in conscience to decide to refuse treatment that would only secure a precarious and painful prolongation of life, but without interrupting the normal treatment due to the patient in similar cases. Hence the doctor need have no concern; it is not as if he had failed to assist the person in danger."

The administration of food and liquids, even artificially, is part of the normal treatment always due to the patient when this is not burdensome for him: their undue suspension could be real and properly so-called euthanasia. (Footnotes omitted.)

This has been recognized by the U. S. Bishops' Conference. A statement of the NCCB Pro-Life Committee reads: "We hold for a presumption in favor of providing medically assisted nutrition and hydration to patients who need it, which presumption would yield in cases where such procedures have no medically reasonable hope of sustaining life or pose excessive risks or burdens."

8. A mentality ever less ready to recognize life as a value in itself, relative to God alone, independent of how it came into being; a concept of the quality of life in terms of efficiency and psychophysical satisfaction, incapable of seeing any meaning in suffering and handicap, and hence to be avoided at any cost and by every means; a vision of death as an absurd end to a life still to be enjoyed, or as a liberation from an existence already considered meaningless; all of this ­ within a culture which, leaving God aside, makes man responsible to himself alone and to freely established laws of society ­ is the soil of the euthanasia culture. Where these convictions are disseminated "it could seem logical and 'human' to end one's own life or that of another 'peacefully', when all that is left to it is suffering and serious impairment."

Charter, #147; John Paul II, To the participants at the 54th Updating Course of the Catholic University, Sept. 6, 1984, in Insegnamenti VII/2, 333-334.

9. Evangelium vitae, 57.

10. NCCB, "Nutrition and Hydration."

Father Edward J. Richard , MS., DTh. M.JD, teaches moral theology and medical ethics at Kenrick / Glennon Seminary in St. Louis.