"Catholic Church Teaching on the Subject of End-of-Life Issues"

The events of the last several months regarding the passing of Terri Shiavo have caused many in the general community and among Catholics to question the moral and legal issues that must be resolved when we face the pending death of a loved one. Indeed, we each must face our own passing and should be concerned about these issues as they relate to ourselves.

We also have the cherished memory of the courageous example of our late Holy Father John Paul II who bore his illness and challenges with grace and dignity. His decision to remain in his home and not go to the hospital teaches us a great lesson: that is, when death is near, one is not obliged to heroic measures to preserve life or to prolong the act of dying.

A. What is the basic teaching of the Church with respect to end-of-life decisions?

The first teaching is the well-known distinction between what has been called “ordinary” and “extraordinary” treatment. This distinguishes treatment that is reasonable or proportionate, from that treatment which becomes unreasonable, or disproportionate, with respect to the health condition of the patient.

Briefly, treatment is ordinary if the treatment will benefit the patient, and in this type of situation, such treatment is absolutely required. Treatment that becomes unreasonable, or disproportionate to the condition of the patient, is no longer required. This evaluation comes after careful medical assessment of the patient. This has been the traditional teaching for over 500 years, and this distinction is central to all the discussions concerning end-of-life decisions.

The 1980 Vatican Declaration on Euthanasia expressed this as follows: “It is also permitted, with the patient’s consent, to interrupt these means where the results fall short of expectations." This statement actually dates from earlier teachings of Pope Pius XII in 1957.

In his famous 1957 Allocution on this subject, Pope Pius XII said this about the difference between ordinary and extraordinary treatment: “…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.”

Further, he said, “The requirement of anything more strict would be too burdensome for most men and would render the attainment of the higher, more important good, too difficult.” In this last sentence, the Pope was referring to our final and eternal end in life. This Allocution by Pope Pius XII represents one of the most significant teachings on this subject of end-of-life treatment.

It is very important to understand that these terms, ordinary and extraordinary, are used in their moral sense, and not as technical medical terms. That is, a procedure such as a blood transfusion or heart massage, may be very customary or ordinary as a medical procedure, but for this particular patient given their health condition, it might be extraordinary or disproportionate at this time.

B. What about providing proper comfort care to the person?

The Church tradition makes another very important distinction between what can be called treatment of the illness, as compared to comfort care for the person.

Treatment of the illness means that the medical team will do everything possible to use what is available to treat the patient so as to heal or at least ameliorate the illness or health condition of the patient. With respect to providing this treatment, the medical team will be guided by the distinction between what is proportionate and when it is no longer proportionate.

Once the decision is made to no longer treat the illness, then there is a very serious obligation to provide comfort care directed to the person. At this point, death is recognized as inevitable, and there is no longer an effort to treat or cure the illness, but now, to provide comfort care for the person. The focus of attention now is to maintain the comfort and dignity of the person.

In effect, Pope John Paul made this basic decision when he chose to remain in his home rather than go to the hospital for continued treatment of his illness.

The person can decide for themselves when the treatment is no longer reasonable, or they can appoint a surrogate to make this decision in case the person is not able to speak for themselves. That is the basic purpose of the current Ohio law on Advanced Directives and the Durable Power of Attorney for Health Care Decisions. This law became effective in 1991, and the basic provisions are not inconsistent with Catholic Church teaching on this subject.

C. Is the removal of life-sustaining treatment the same as euthanasia or suicide?

Many have asked if “allowing a person to die” is the same as suicide or, perhaps, euthanasia. Our Church teaches very clearly that it is not. The Catechism of the Catholic Church provides a very clear answer to this question. Speaking of the subject of removing medical procedures that are disproportionate, the Catechism says (in #2277): “Here, one does not will to cause death; one’s inability to impede it is merely accepted.”

Pope John Paul wrote in his encyclical Evangelium Vitae that “…this is not suicide, but an acceptance of the human condition or a wish to avoid the application of medical procedures disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community.” (Evangelium, 1995, #65)

The 1980 Vatican Declaration on Euthanasia expressed this same thought: “Such a refusal is not the equivalent of suicide; on the contrary, it should be considered 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 on the community.”

Thus, as expressed in these two citations, the decision to refuse disproportionate treatment is not a decision to end one’s life, but to tolerate life’s passing rather than add to the burdens that are already present, to seek no longer to bear these burdens, now judged to be useless and futile. It is never the life of the person that is a burden, but the treatments themselves that no longer offer any benefit to the patient.

Many similar citations from the rich treasure of Catholic Church teaching can be added. The basic approach that the Church has developed for over 500 years can be expressed very simply and that is, that once it is determined that death is imminent or inevitable, it is no longer necessary to administer procedures whose only purpose it is to extend the act of dying.

D. But what about the provision for nutrition and hydration therapy to provide for comfort?

This question is usually asked with respect to what is called artificially supplied nutrition and hydration therapy, called ANH. This means to provide food nutrients and liquids for the patient. The question is usually asked and was asked about Mrs. Shiavo, can we allow a person to starve to death? Can we allow them to be deprived of water or liquids?

For many patients, during routine treatment for their illness, the use of artificially supplied nutrients and liquids is absolutely necessary, ordinary, and mandatory. There is never a question about this kind of situation. For these patients, it is a temporary medical procedure while they are recovering, perhaps from surgery or some other medical condition.

The question that many are asking is this: Once the decision is made to withdraw the life-sustaining treatment because the medical team has determined that this patient’s illness is no longer treatable, then under what circumstances may these provisions for artificially supplied nutrition and hydration be removed from such a patient?

E. Are there any guidelines to help make this decision concerning this removal?

We have a wonderful resource in a teaching provided by our Catholic Bishops, and this is entitled, the Ethical and Religious Directive for Catholic Health Facilities. The following is taken from the latest edition, 2001, #58.

There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, so long as this is of sufficient benefit to outweigh the burdens involved to the patient.

This paragraph gives us a moral framework to offer guidelines to assist individuals and families, as well as medical and hospital personnel, to help in the resolution of these very difficult end-of-life decisions.

F. What are some practical guidelines on this question of artificial nutrition and hydration (ANH)?

First, certainly, is the very strong presumption to provide this form of comfort care to the patient. In other words, we begin with this strong presumption to begin or maintain this procedure unless there is a very clear reason to withdraw or withhold the ANH

Once the medical evaluation is made that these procedures are not of any benefit to the patient, or in some circumstances, actually result in a burden, or if the procedures do nothing but prolong the act of dying, under these circumstances, it is morally permissible to withdraw the artificially supplied nutrition and hydration from the patient. This must be confirmed by the patient’s physicians.

During these last moments, there are medically available procedures to maintain the person in comfort so that there will be no suffering. These include pain management and procedures to reduce the effects of dehydration.

Again, we mention the example of Pope John Paul, who by choosing not to go to the hospital, chose instead to allow his natural passing without the intervention of the heroic use of extensive nutrition and hydration therapy. He chose to die in peace.

G. What about the Allocution that Pope John Paul gave in March of 2004 concerning the use of artificially supplied nutrition and hydration?

The Pope’s Allocution was directed very specifically to patients who are in a condition that is technically called the Persistent Vegetative State. The Allocution applies only to those in this condition. This is often referred to as the state of PVS.

In April of 2004, the Cleveland Diocese issued a formal statement on this Allocution. This statement was addressed to Catholic hospitals, nursing homes, and pastors in our parishes.

H. What is the main issue that was addressed in this diocesan statement?

The issue that was addressed specifically was the current law of the State of Ohio dealing with end- of-life issues. This law provides for the Advanced Directives for Health Care and for the Durable Power of Attorney for Health Care. The law became effective in October 1991.

The following is a very brief summary of the central points of the diocesan statement:

At issue is a provision of this law (which is set forth in a specially designated paragraph) that allows a physician, under very specific and strict conditions, to remove artificial nutrition and hydration from a patient who is diagnosed to be in what is called a permanent unconscious state. Note, the specific diagnosis in this law is a patient who is in a permanent unconscious state, not in a Persistent Vegetative State.

This is the most important part of the statement from the Diocese. Since this provision of the law applies to a different medical condition than what was addressed in the Allocution, the instruction from the Diocese presents a clarification that the current Ohio law on this issue can remain in force in our hospitals and nursing homes.

The important teaching from the diocesan statement reads as follows with regard to that special section of the Ohio Advanced Directives that addresses this issue:

Since this Allocution deals only with the clinical state of PVS, it will be the decision of the medical specialists who attend to the patient to decide when this paragraph is to be implemented. If the patient is indeed in this clinical state, then the paragraph will not apply, and the assisted care will not be withdrawn.

It is, therefore, the role of the medical personnel who are attending to this patient to make the appropriate medical diagnosis.

I. Some concluding practical suggestions for families:

First, it is strongly encouraged that every person complete the Ohio Advanced Directive and Durable Power of Attorney forms in order to protect the right of self-determination in health-care decisions. These directives are consistent with Catholic Church teaching. These are legal forms and should be processed by those skilled to present them. You are encouraged to seek professional resources assist you.

Second, it is essential that each person discuss these matters with family members so that everyone understands your personal wishes. Third, certainly, is the need to discuss these issues with your personal physician, as well as your legal counsel.

For directions to assist in obtaining copies of the Ohio Directives for Health Care, call the Continuing Education Services at the following Catholic hospitals:

Marymount ~ 216-581-0500

St. Vincent Charity ~ 216-861-6200

St. John West Shore ~ 440-835-8000