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GENERAL POLICY ON THE USE OF  LIFE-SUSTAINING TREATMENTS

Explanation of Terms and Procedures 

            A life-sustaining treatment is any medical intervention, technology, procedure, or medication that is administered to a patient in order to forestall the moment of death, whether or not the treatment is intended to affect the underlying life-threatening disease(s) or biologic processes. (1) Examples include respirators, kidney dialysis, antibiotics and cardiopulmonary resuscitation.  

Policy 

            Decisions about the use of life-sustaining treatments should be made on the basis of a consideration of benefits and burdens. It is permissible to forgo, that is, to withhold or withdraw, a life-sustaining treatment which does not offer a reasonable hope of benefit or entails an excessive burden for the patient or which imposes excessive expense on the family or the community. Benefits and burdens should be assessed from the patient’s point of view. 

            The free and informed decision of the patient or, if the patient is incompetent, of his/her surrogate decisionmaker about the use or forgoing of life-sustaining treatments should be complied with, provided that it does not contradict Catholic moral teaching and principles. 

            A surrogate decisionmaker should make decisions in accord with the patient’s intentions and values, or if the patient’s wishes are unknown, in accord with the patient’s best interests.

 

Sources of Policy 

            These policy statements are based on the Ethical and Religious Directives for Catholic Health Care Services from the National Conference of Catholic Bishops (2): 

While every person is obliged to use ordinary means to preserve his or her health, no person should be obliged to submit to a health care procedure that the person has judged, with a free and informed conscience, not to provide a reasonable hope of benefit without imposing excessive risks and burdens on the patient or excessive expense to family or community. (no. 32)

 

A person has a moral obligation to use ordinary or proportionate means of preserving his or her life. Proportionate means are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community. (no. 56)

 

A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patient’s judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community. (no. 57)
The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life-sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching. (no.­59)

 

Each person or the person’s surrogate should have access to medical and moral information and counseling so as to be able to form his or her conscience. The free and informed health care decision of the person or the person’s surrogate is to be followed so long as it does not contradict Catholic moral principles. (no. 28)

 

Each person may identify in advance a representative to make health care decisions as his or her surrogate in the event that the person loses the capacity to make health care decisions. Decisions by the designated surrogate should be faithful to Catholic moral principles and to the person’s intentions and values, or if the person’s intentions are unknown, to the person’s best interests... (no. 25)

 

 

          1. The Hastings Center, Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying (Briarcliff Manor, NY:  The Hastings Center, 1987), p. 4. 

          2. National Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services (November 1994) (Washington, D.C.: United States Catholic Conference, 1995).

COMMENTARY 

GENERAL POLICY ON THE USE OF LIFE-SUSTAINING TREATMENTS 

 

The Ordinary/Extraordinary Treatment Distinction and the Benefits and Burdens Principle 

Historically, Catholic moralists have drawn a distinction between ordinary and extraordinary treatments, and employed the principle that ordinary treatments must always be provided whereas the use of extraordinary treatments is not obligatory. However, problems with this distinction have been noted by ethicists. (1) The Vatican Declaration on Euthanasia (1980) explicitly moves away from this terminology to speak in terms of proportionate and disproportionate means (2), which is now commonly interpreted in terms of a consideration of benefits and burdens. This evolution of terminology is made explicit in the 1994 revision of the Ethical and Religious Directives for Catholic Health Care Services: 

A person has a moral obligation to use ordinary or proportionate means of preserving his or her life. Proportionate means are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or community. (no. 56)

 

A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patient’s judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community. (no. 57) (3) 

The benefits and burdens principle does not represent a completely new moral criterion for the use of life-sustaining treatments, but rather, is an attempt to bring about greater clarity and precision by focusing on one of the traditional interpretations of the ordinary/extraordinary distinction. (4) 

            The ordinary/extraordinary treatment distinction seemed to label treatments as such (e.g., aspirin is “ordinary” and must always be given when needed, kidney dialysis is “extraordinary” and may be forgone). According to the benefits and burdens principle, on the other hand, there is no medical treatment whose use is always mandatory nor is there any medical treatment which can automatically be forgone. Rather, decisions must be made on a case-by-case basis. The question to be asked is:  What will this treatment do for this particular patient who is in these particular circumstances? Thus some medical treatments, such as antibiotics, may be commonly available and commonly used yet burdensome in some respects or to some patients, or even futile in some cases. When excessively burdensome or giving no reasonable hope of benefit, even such common treatments may be forgone. 

Explanation of the Benefits and Burdens Principle 

            According to the Ethical and Religious Directives for Catholic Health Care Services, it is permissible to forgo a treatment which does not offer a reasonable hope of benefit. (5) This document also uses the terminology “insufficiently beneficial” and “useless.” (6) Thus this part of the benefits and burdens principle introduces the issue of medical futility.

            In the current literature the very meaning of “futility” is being debated. Quite different interpretations have been attached to the notion of “medical futility” by various healthcare professionals and ethicists. Some understand it on a purely physiological level, so that a medical procedure is futile if it simply will not work (e.g., CPR which will not succeed in reestablishing spontaneous heartbeat). Others understand futility probabilistically, so that a procedure whose probability of success is extremely low is considered futile (e.g., CPR with less than a 1% probability of succeeding). Yet others interpret futility in terms of the failure of a treatment to postpone death. Still others consider time and length of life in making judgments about futility (e.g., a life saved for only a few days, a patient who lives a week after CPR but dies before discharge). Finally, some give a quality of life analysis of futility, so that a treatment is considered futile if it does not succeed in restoring a patient to a certain functional level (e.g., leaves permanently unrestored a patient's neurocardiorespiratory capacity, does not alter a patient’s persistent vegetative state). (7) 

            It is important to recognize that a particular medical procedure might be judged “futile” according to one criterion but not according to another. For example, a patient's serum sodium level might be kept within normal limits in a patient whose condition is rapidly deteriorating, but the procedure may fail to postpone the patient’s death by even a few minutes. According to the physiological criterion, the procedure would not be considered futile but would be such according to the criterion of postponing death. (8) Or again, an intervention might keep a patient alive for six months but not achieve an important goal of the patient, for example, being able to walk and take care of his/her own personal hygiene. Judging futility in terms of postponing death or in terms of time and length of life, the procedure would not be considered futile. On the other hand, it would be judged futile in terms of considerations of quality of life.  (9)         

            The Ethical and Religious Directives for Catholic Health Care Services leaves open the question of how “no reasonable hope of benefit” is to be interpreted. 

            According to the Ethical and Religious Directives, it is also morally permissible to forgo a life-sustaining treatment which is excessively burdensome for the patient. (10) What constitutes an “excessive burden”? Since the term “excessive burden” is used in explanation of the “disproportionate means” spoken of in the Vatican Declaration on Euthanasia, it is useful to read the Ethical and Religious Directives against the background of that document: 

In any case, it will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected... (italics added). (11)

 

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... (italics added). (12) 

These texts suggest a process of weighing benefits and burdens, so that a treatment would be considered “excessively burdensome” for a patient if the burdens outweigh the benefits. (13) 

            Among ethicists there is still discussion and controversy about the meaning and scope of the benefits and burdens principle. Should the benefits and burdens considered be those affecting the patient exclusively, or should benefits and burdens for others (e.g., for the patient’s family, for society) be taken into account as well? Should the benefits and burdens considered be purely medical in character (e.g., pain and discomfort for the patient), or should non-medical factors (e.g., cost, the patient’s emotional state, psychological strain on caregivers) likewise figure into the decision? Does the concept of burdensomeness apply only to medical treatments as such, or can the life that is so sustained itself be considered burdensome? Can evaluations of benefits and burdens be specified independent of, or only in light of, a particular patient’s circumstances and values? (14) 

            Some ethicists wish to limit benefits and burdens to those pertaining to the patient alone. (15) This position is undoubtedly motivated by a desire to protect patient rights so that a patient’s life will not be unwarrantedly cut short by “burdens” on caregivers. The Ethical and Religious Directives clearly speaks of benefits and burdens for the patient (16) but go beyond this in speaking of what imposes “an excessive expense on the family or community” as a factor making it legitimate to forgo life-sustaining treatment. (17)  But a question is left unresolved:  Is it legitimate to take into account burdens on others which are other than financial? In an address to anesthesiologists which has become an important document in Catholic healthcare ethics, Pope Pius XII spoke of “burdens for others” generically in using the phraseology “means that do not involve any grave burden for oneself or another” (18). And some Catholic moralists have clearly used a broader interpretation of “burdens for others” than simply including financial ones. (19) 

            Taking into account the cost of treatments is including “non-medical” factors in the consideration of benefits and burdens. One can find yet other types of “non-medical” factors considered by Catholic moralists, for example, the travel distance to undertake a treatment. (20) 

            Whether the concept of burdensomeness applies only to medical treatments as such or whether the life that is sustained through medical treatments can itself be considered burdensome is a question that is not explicitly addressed by the Ethical and Religious Directives. For example, suppose a patient in the late stages of terminal cancer contracts pneumonia that is treatable by antibiotics. The administration of the antibiotics per se may not be “burdensome,” but prolonging the patient's life through the use of antibiotics may only increase the suffering of the dying process. The Vatican Declaration on Euthanasia states that “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...”(italics added; 21). This phraseology suggests that the “burdensomeness of the life sustained” may be taken into account, at least when a patient is in the final terminal stages of a disease. 

            Finally, the Ethical and Religious Directives makes clear that the assessment of benefits and burdens is done according to “the patient's judgment.” (22)  On one level, this means that the patient himself/herself is the decisionmaker; it is not appropriate for someone other than the competent patient to “look from the outside” and render a judgment about the benefits and burdens involved in a case. On another level, this entails that different patients who have similar physical conditions may make different judgments about the burdensomeness of undertaking a treatment because of e.g., differences in psychological stamina or differences in age. 

 

Withholding vs. Withdrawing Treatments 

            In the past some have made a distinction between withholding and withdrawing treatments, believing that withholding a life-sustaining treatment may be morally permissible but that, once initiated, withdrawing a treatment is wrong. This kind of thinking has changed. Withholding and withdrawing treatments are now placed on a par. Ethically and legally, it is considered just as permissible to withdraw a treatment as never to start it. (23) In fact, the practice of time-limited trials of life-sustaining treatments is encouraged since one may not be sure in advance if a particular treatment will benefit a patient. (24) 

            The Vatican Declaration on Euthanasia explicitly allows the withdrawal of life-sustaining treatments: “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.... It is also permitted, with the patient’s consent, to interrupt these means, where the results fall short of expectations.” (25) Similarly, the Ethical and Religious Directives for Catholic Health Care Services states that “the free and informed judgment made by a competent adult patient concerning the use or withdrawal of life-sustaining procedures should always be respected and normally complied with..." (26; italics added). 

 

Patient Autonomy 

            A central principle in contemporary healthcare ethics is patient autonomy, which basically means the right of a patient to be involved in decisionmaking about medical treatments and indeed to make the final decision about using or forgoing treatments. (27) In the case of an incompetent patient, an appropriate surrogate decisionmaker is involved in the decisionmaking process in the patient's stead. The 1994 revision of the Ethical and Religious Directives incorporates the concept of patient autonomy: 

The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life-sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching.  (no.­59)

 

Each person or the person’s surrogate should have access to medical and moral information and counseling so as to be able to form his or her conscience. The free and informed health care decision of the person or the person’s surrogate is to be followed so long as it does not contradict Catholic moral principles. (no. 28) 

            Sometimes patient autonomy is presented in such a way that healthcare professionals are expected to abide by the wishes of a patient no matter what he or she wants and no matter what the rationale of his or her decision. Decisions should be made by patients or their surrogates in consultation with healthcare professionals. Further, the 1994 Ethical and Religious Directives places a restriction on patient autonomy:  one abides by the decision of the patient provided that it does not contradict Catholic moral principles. Thus a patient should not make a decision about forgoing life- sustaining treatments arbitrarily, but should make it using the principle of benefits and burdens. If a patient were to make a decision about life-sustaining treatments which contradicted the decision which s/he would reach using the benefits and burdens principle, then there is no moral obligation on the part of healthcare providers to follow the patient’s wishes. 

 

Surrogate Decisionmakers 

            A surrogate decisionmaker is an individual who makes healthcare decisions for a person who is not competent to do so. This role is often fulfilled by the patient’s next of kin, but another relative, a close friend, an individual who knows the patient well, or a legally appointed proxy decisionmaker or guardian may serve in this capacity. The official policies of healthcare institutions or legislative acts relating to healthcare may establish prioritized lists of individuals to serve as surrogate decisionmakers. For example, Iowa’s Life-Sustaining Procedures Act establishes the following prioritized list: the attorney-in-fact (i.e., the individual designated as proxy decisionmaker in a Durable Power of Attorney for Health Care); the patient’s guardian; the patient’s spouse; an adult child of the patient or, if the patient has more than one adult child, a majority of the adult children who are reasonably available for consultation; a parent of the patient, or parents if both are reasonably available; an adult sibling. (28) 

            The preferred standard for surrogate decisionmaking is the principle of substituted judgment. In this case, the surrogate decisionmaker knows the patient well enough to be able to predict what the patient would want in the case at hand if the patient were able to make a judgment. In other words, the surrogate decisionmaker makes a decision in accordance with the values and desires of the patient. When such a surrogate decisionmaker cannot be found, the best interests standard is used in which the proxy objectively attempts to assess what is best for the patient. (29) The Ethical and Religious Directives incorporates these two standards in the customary prioritized order: “Decisions by the designated surrogate should be faithful to Catholic moral principles and to the person’s intentions and values, or if the person’s intentions are unknown, to the person’s best interests.” (no. 25) 

 

Euthanasia and Assisted Suicide 

            Forgoing life-sustaining treatments is not to be equated with euthanasia or assisted suicide. Morally, there are cases in which forgoing life-sustaining treatments is entirely permissible. On the other hand, euthanasia and assisted suicide are never permissible. See the entry Euthanasia and Assisted Suicide.

Nonecclesiastical Documents on Life-Sustaining Treatments 

            It is generally recognized that there are cases in which it is permissible to forgo life-sustaining treatments. For example, the Special Committee on Biomedical Ethics of the American Hospital Association, the Council on Ethical and Judicial Affairs of the American Medical Association, and the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research have all asserted the legitimacy of forgoing such treatments.  (30) 

 

Legal Considerations 

            Since the landmark case of Karen Ann Quinlan in 1976, many courts have recognized a patient’s right to forgo life-sustaining treatments. (31) In the State of Iowa two legal documents are available to enable individuals to express their wishes about life-sustaining treatments should they themselves ever become incapacitated and unable to make their own decisions: the Declaration Relating to Use of Life-Sustaining Procedures (i.e., living will) and the Durable Power of Attorney for Health Care. For further information on these documents, see the entry Advance Directives

            1. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Deciding to Forego Life-Sustaining Treatment (1983; reprint New York: Concern for Dying), pp. 82-9. 

            2. “In the past, moralists replied that one is never obliged to use ‘extraordinary’ means. This reply, which as a principle still holds good, is perhaps less clear today, by reason of the imprecision of the term and the rapid progress made in the treatment of sickness. Thus some people prefer to speak of ‘proportionate’ and ‘disproportionate’ means.” Vatican Congregation for the Doctrine of the Faith, Declaration on Euthanasia (Washington, D.C.: United States Catholic Conference, 1980), p. 8. 

            3. National Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services (November 1994) (Washington, D.C.: United States Catholic Conference, 1995). 

            4. President’s Commission, Deciding to Forego Life-Sustaining Treatment, pp. 84-5. Note also Pope Pius XII’s Address to an International Congress of Anesthesiologists of November 24, 1957: “But 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.” Reprinted in Russell E. Smith (ed.), Conserving Human Life (Braintree, MA: Pope John Center, 1989), p. 315. 

            5. National Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, nos. 32, 57.

            6. Ibid., Introduction to Part Five. 

            7. Stuart J. Youngner, “Who Defines Futility?”, Journal of the American Medical Association 60 (1988) : 2094-95; Stephen G. Post, “Baby K: Medical Futility and the Free Exercise of Religion,” Journal of Law, Medicine & Ethics 23 (1995): 20-26 at 23; Lawrence J. Schneiderman, Nancy S. Jecker, and Albert R. Jonsen, “Medical Futility: Its Meaning and Ethical Implications,” Annals of Internal Medicine 112 (June 15, 1990) : 949-54; Tom Tomlinson and Diane Czlonka, “Futility and Hospital Policy,” Hastings Center Report 25/3 (1995) : 28-35 at 31-33. 

8. Younger, “Who Defines Futility?”, p. 2094. 

9. Ibid. 

10. Directives nos. 32, 57, quoted in this entry in “Sources of Policy.” 

11. Vatican Congregation for the Doctrine of the Faith, Declaration on Euthanasia, pp. 8-9. 

12. Ibid., pp. 9-10. 

            13. Cf. Msgr. Orville N. Griese, Catholic Identity in Health Care: Principles and Practice (Braintree, MA: Pope John Center, 1987), pp. 159-60. 

            14. President’s Commission, Deciding to Forego Life-Sustaining Treatment, pp. 84-5, especially n. 123; Griese, Catholic Identity in Health Care: Principles and Practice, pp. 159-63. 

            15. See, for example, Hastings Center, Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying (Briarcliff Manor, NY: The Hastings Center, 1987), especially p. 19. 

16. Directive no. 32, quoted in this entry in “Sources of Policy.” 

17. Directives nos. 32, 57, quoted in this entry in “Sources of Policy.” 

            18. Pope Pius XII, Address to an International Congress of Anesthesiologists, November 24, 1957 in Smith (ed.), Conserving Human Life, p. 315. 

            19. Consider, for instance, an example given by Griese in Catholic Identity in Health Care: Principles and Practice, p. 160: “Padwel Sitarz, 16, son of a “Solidarity” leader who was freed from prison on condition that he leave his native Poland, was seriously ill with a condition which later was diagnosed as prostate cancer. Knowing that his parents had no money for medical treatment, and convinced that they depended heavily upon his knowledge of English in their difficult period of adjustment to life in a new country (parents unable to speak English), he did not tell them about his illness. On December 12, 1984, he was rushed to the hospital; the cancer had spread to his lungs and stomach; he died on December 15, 1984. Treatment for prostatic cancer would rate medically as an ordinary means of preserving life. For Padwel (“Paul” to his friends) Sitarz, age 16, subjectively considered with all due implications for his loved ones, it was an ethically extraordinary and non- compulsory means of preserving his life.” 

            20. Consider, for instance, an example given by Griese in Catholic Identity in Health Care: Principles and Practice, pp. 160-61: “Another example could be the situation of an elderly woman with advanced kidney dysfunction, whose children are all married and “on their own.” She may choose to regard the prospect of renal dialysis several times each week in a hospital 50 miles distant from her place of residence as an excessive burden--hence as an extraordinary and noncompulsory means of preserving her life.” 

21. Vatican Congregation for the Doctrine of the Faith, Declaration on Euthanasia, p. 10. 

22. Directives nos. 56-57, quoted in this entry in “Sources of Policy.” 

            23. President’s Commission, Deciding to Forego Life-Sustaining Treatment, pp. 73-77; Hastings Center, Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying, pp. 5-6. Within the State of Iowa, the Life-Sustaining Procedures Act explicitly establishes that “any competent adult may execute a declaration at any time directing that life-sustaining procedures be withheld or withdrawn.” (Code of Iowa 144A.3). 

            24. Hastings Center, Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying, pp. 5-6, 30, 130-31. 

25. Vatican Congregation for the Doctrine of the Faith, Declaration on Euthanasia, p. 9. 

26. Directive no. 59. 

            27. Hastings Center, Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying, p. 7, 19. 

28. Code of Iowa 144A.7. 

            29. President’s Commission, Deciding to Forego Life-Sustaining Treatment, pp. 133-36. 

            30. Values in Conflict Resolving Ethical Issues in Hospital Care Report of the Special Committee on Biomedical Ethics of the American Hospital Association (Chicago: American Hospital Association, 1985), pp. 14-15, 19; Council on Ethical and Judicial Affairs of the American Medical Association, “Euthanasia” (June 1988) in Reports (Chicago: American Medical Association); President’s Commission, Deciding to Forego Life-Sustaining Treatment, especially p.­90. 

          31. Hastings Center, Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying, pp. 4, 152-53.

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