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 | By Deacon G. Neal Kay, M.D.

A Catholic Perspective on End-of-Life Care

During a career in medicine, I have encountered numerous situations where a patient and their family are uncertain what the Church teaches regarding ethical issues surrounding end-of-life care. Families want to make their loved one who is suffering from a terminal illness comfortable, but they often have questions regarding whether certain treatments can be ethically refused, whether some treatments should be continued, or whether a previously implemented therapy can be withdrawn. And most importantly, knowing who should speak for the patient when they are no longer able to express their own wishes for medical care is of vital importance. It is my hope that the following discussion will address many of the more common issues that patients and their loved ones may face surrounding times of severe illness.

A serious illness is a time of distress both for those who are suffering the effects of disease or trauma and those who love and care for them. Making sound moral decisions in the face of the emotional turmoil that comes with watching a loved one suffer is often especially difficult. The teachings of the Catholic Church offer considerable help in making end-of-life decisions that are both morally licit and compassionate.

The redemptive nature of suffering

Suffering and death are the consequences of the sin of our first ancestors, but Christ’s obedience to the Will of the Father can now infuse these afflictions with great redemptive power. By virtue of our being made one with Christ in baptism, we can join our suffering to that of Jesus on the Cross and assist in His work of salvation for the entire human race. Just as Christ is with us and shares in our suffering, so too, can we share in His. For those who live without faith, a time of illness and suffering can lead them to consider suicide or euthanasia. However, the Catholic Church teaches that intentionally ending the life of oneself or another is wrong.

Ordinary versus extraordinary care

The Church recognizes that some medical treatments may be morally obligatory while others are morally optional. Ordinary means of preserving life are all medications, treatments, and operations which offer a reasonable hope of benefit and which can be obtained and used without excessive expense, pain, or other inconvenience. These include such natural provisions as food, air, and water. In some situations, ordinary care would include easily performed medical procedures that do not impose an undue burden on the patient or their community. Ordinary care is obligatory but can become extraordinary under certain situations. There must be some hope of benefit; the dangers must be outweighed by the benefit; and the costs can be considered. In contrast, extraordinary means of preserving life are all medications, treatments, and operations which cannot be obtained and used without excessive expense, pain, or which, if used, would not offer a reasonable hope of benefit. These include care whose provision involves a disproportionately great burden on the patient or their community and, hence, are not morally obligatory. These treatments would include those offering a lack of benefit; producing excessive hardship; excruciating or excessive pain; extraordinary expense; intense fear or repugnance.  Examples might include hemodialysis, an implantable cardioverter defibrillator (ICD), or mechanical ventilators when there is no reasonable chance of benefit.

The principle of double effect

One concern is whether a treatment can provide benefit but might, in some cases, have undesired side effects. This is termed the principle of double effect. A common example of the principle of double effect would include the use of narcotic medications which are intended to relieve severe pain. While these medications can potentially suppress respiration, if the intention is to relieve suffering but not interfere with breathing, then such a side effect would not be morally illicit.  Classical formulations of the principle of double effect require that four conditions be met if the action in question is to be morally permissible. First, the action contemplated must be, in itself, either morally good or morally indifferent. Second, the bad result cannot be directly intended. Third, the good result cannot be a direct causal result of the bad result. Fourth, the good result must be "proportionate to" the bad result.

Withholding care and withdrawal of care: substitution versus replacement therapies

The ethical issues with withholding a therapy may differ from withdrawing a therapy. For example, a patient with coronary artery disease has the right to refuse to have a coronary artery bypass operation. Similarly, a patient with renal failure may agree or refuse to begin hemodialysis. They may refuse to have a permanent pacemaker implanted if they would otherwise have an indication. But, can a patient ask to have a previously initiated therapy withdrawn? Here, the distinction is made based on whether a therapy is a replacement or a substitution. Generally, a replacement therapy cannot be ethically withdrawn while a substitution therapy can be withdrawn.

A replacement therapy is a technological intervention that participates in the organic unity of the patient as an organism. These treatments do not require medications to control, are not painful or onerous, do not require adjustment by the patient or physician, and respond to the changing physiology of the patient. Examples include kidney transplantation, heart valve replacement, or a permanent pacemaker. It would not be morally licit to remove these therapies so that a patient could be allowed to die of an underlying disease such as cancer.

In contrast, a substitution therapy is one that is not integrated into the body, that often presents discomfort or burden to the patient, and requires repeated adjustment or medical intervention.  Examples might include hemodialysis, an implantable cardiac defibrillator, or a mechanical ventilator. It would be morally acceptable to withdraw these forms of substitution therapies in the presence of a terminal illness should the patient request.

Advance Directives and Medical Power of Attorney

An Advance Medical Directives (Living Will) is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. In the United States it has legal status. An example would be a Do Not Resuscitate Order (DNR) or Do Not Intubate Order (DNI). An Advance Medical Directive usually stipulates specific directives about the course of treatments that are to be followed by healthcare providers and caregivers. In some cases, an Advance Medical Directive may forbid the use of various kinds of burdensome medical treatment. An Advance Medical Directive is used only if the individual becomes unable to give informed consent or refusal due to incapacity. An Advance Medical Directive can be very specific or very general. An example of a statement sometimes found in an Advance Medical Directive is: “If I suffer an incurable, irreversible illness, disease, or condition and my attending physician determines that my condition is terminal, I direct that life-sustaining measures that would serve only to prolong my dying be withheld or discontinued.”

In contrast to an Advance Medical Directive, Durable Powers of Attorney for Health Care and “Healthcare Proxy Appointment” documents allow an individual to appoint someone to make healthcare decisions on their behalf if they should ever be rendered incapable of making their wishes known. The appointed healthcare proxy has, in essence, the same rights to request or refuse treatments that the individual would have if they were still capable of making and communicating health care decisions for themself.

The differences between Advance Medical Directives and Health Care Proxies lead to some advantages and disadvantages of each. If the Advance Medical Directive is very restrictive, it may lead to withholding care that might be reasonable under some specific conditions. For example, if an Advance Medical Directive explicitly states that the patient does not want to be on a ventilator if critically ill, this could result in withholding care for a reversible condition such as pneumonia where a ventilator might be required for only a few days before full recovery. In such a situation, a patient would likely agree to be placed on a ventilator if recovery was highly likely.  In contrast, if a medical condition is irreversible, then placing them on a ventilator would likely not be what they would desire. Because of the nuances of medical conditions, having a person who knows the desires of a patient and who can speak for them may allow more flexibility when providing care. Thus, a Health Care Proxy is often an excellent way to allow the wishes of a patient to be considered when they have someone they trust to speak on their behalf. However, if a patient does not have a friend or family member whom they trust to make difficult medical decisions, a Health Care Proxy designation can be problematic, and an Advance Medical Directive may be the better solution.

In summary, dealing with the complexities of medical care at the end of life requires forethought.  Having a friend or family member who knows the wishes of the patient and the teachings of the Catholic Church, a person whom they trust to act on their behalf, is an ideal situation to designate a Health Care Proxy and is often the preferred approach. If such a person is not available, then an Advance Medical Directive may be the better choice. Your family, your physician, priest, deacon, or religious sister or brother can help you effectively plan for end-of-life medical care that will provide you with confidence that the teachings of the Church will be respected.

Deacon G. Neal Kay, M.D., is a permanent Deacon at St Francis Xavier parish in Birmingham.  He is Professor Emeritus at the University of Alabama at Birmingham and former Director of Cardiac Electrophysiology. He has over 300 scientific publications including in the field of medical bioethics.