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Advance "Mis-Directives":
Euthanasia in Catholic Hospitals in the United States


by George Isajiw, M.D.
Past President, Catholic Medical Association, USA
23 North Lansdowne Avenue, Lansdowne, Pennsylvania, 19050 USA

The Magisterium of the Catholic Church, in the 1980 "Declaration on Euthanasia" of the Sacred Congregation for the Doctrine of the Faith, defines euthanasia as "... an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated".

In the United States, this statement is quoted in the Ethical and Religious Directives for Catholic Health Care Services (Fourth Edition), issued on June 15, 2001 by the United States Conference of Catholic Bishops.

The 1980 Vatican Declaration on Euthanasia emphasizes the traditional distinction between "ordinary" and "extraordinary" treatments, indicating that only "ordinary" treatments are obligatory. "Extraordinary treatments", even though risky and burdensome, CAN be used "--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."

What is important to note is that while "extraordinary" treatments are not obligatory, using them DOES NOT constitute any moral harm to the patient, even if the treatment cannot, in effect, achieve its goal to sustain life or improve health. The Vatican document further states that "... it is also permitted, with the patient's consent, to INTERRUPT these means [treatments], where the results fall short of expectations."

Most importantly, however, the authors of the Vatican document provide a safeguard against an arbitrary withdrawal of beneficial treatment by the patient or the patient's family with the following statement: "... 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 the ADVICE OF THE DOCTORS WHO ARE SPECIALLY COMPETENT IN THE MATTER".

If "extraordinary" treatment is defined as a treatment which has ceased to be of benefit (that is, can no longer achieve its intended therapeutic effect under the particular clinical circumstances), or has become too burdensome (that is, even if a therapeutic benefit still exists, the burden imposed upon the patient by the treatment itself is out of proportion to the benefit), it is necessary for someone to make a JUDGMENT that a given treatment does, in fact, meet the criteria of being "extraordinary" in the moral sense. While it is always the PATIENT (or in the case of incompetence, the patient's surrogate) who makes the DECISION whether or not to withdraw treatment (and this is of utmost importance because the patient has the right to continue treatment EVEN if it is judged to be"extraordinary" treatment), the Vatican document clearly states that it is the PHYSICIAN who must make the JUDGMENT that a given treatment is, or has become "extraordinary". I further quote: ".... The latter [i.e. the physicians] 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.

The "Declaration on Euthanasia" also teaches that the same treatment which is ordinary in some circumstances can become "extraordinary" in others, depending on the clinical situation: ".... 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." Thus, a particular treatment, such as a ventilator, which would be "ordinary" for a reversible pathology such as an infectious pneumonia, can become "extraordinary" in the case of irreversible respiratory failure.

To put it in the words of the late Dr. Joseph Gambescia, who was my mentor in medical ethics: "It is the doctor who makes the JUDGMENT, and it is the patient who makes the DECISION". One cannot act ethically without the consent of the other. The patient has the right to continue any treatment, even if in the opinion of the physician a given treatment is judged to be "extraordinary". This protection for the patient reaffirms the "Sanctity of Life", and reassures us that no treatment on behalf of sustaining life, even if extraordinary or "useless", can be considered objectively harmful, immoral or unethical.

As we all know, especially in the so-called developed societies such as the United States and Europe, euthanasia is becoming accepted as a way of solving the problem of suffering and advancing age. While this trend is clearly recognized in secular institutions, it is also rearing its "ugly head" in Catholic health care facilities as well. There is a wide-spread attempt to justify both active and passive euthanasia among Catholic ethicists through the false application of the principles of "ordinary" and "extraordinary" means, and the false application of the principle of patient "autonomy".

It has become particularly popular to falsely apply the principles and legal distinctions of so-called "Advanced Directives", or "Living Wills", in order to promote euthanasia in Catholic hospitals.

As a matter of fact, the entire concept of "Advance Directives" had been introduced by pro-euthanasia forces in the United States as a first step in legalizing euthanasia. Unfortunately, because one can "theoretically" rationalize the use of advance directives as merely a means of expressing the desire to avoid "extraordinary" treatment, the Catholic Church in the United States has endorsed the concept of living wills and they are promoted as a means of expressing legitimate autonomy and legitimate end of life decisions. Laws regarding such directives are enacted on the state level, and there are many different versions of these laws in the 50 United States. Most were supported by the respective state Bishops Conferences because it was thought that the wording of the laws protected patients from the practice of euthanasia. But in actual practice, the laws, which few people know or understand, are used as a pretext for promoting euthanasia, just as originally intended by pro-euthanasia forces.

I have collected a series of case histories involving my own patients at my Catholic hospital, Mercy Fitzgerald Hospital, Darby, Pennsylvania, USA -- part of the Mercy Health System administered by the Sisters of Mercy. Most of these cases involve the refusal by the surrogate decision makers to consent to the use of ventilators or feeding tubes under circumstances where they would have been ordinary treatment for a non-terminal patient with a reversible pathology. A typical example is an incompetent patient who has had a stroke with paralysis and dysphagia, who needs a long term feeding tube, and who is otherwise medically stable and death is NOT imminent. The provision of tube feeding is certainly useful in providing nutrition and hydration and the burden does NOT outweigh the benefit. However, because the patient may have an "advance directive" which specifically states that feeding tubes are NOT to be used, the family insists that it is the patient's wish to be allowed to die from dehydration under such circumstances. Even though Pennsylvania State Law specifically states that the "Advance Directive" has NO significance UNLESS the patient is both incompetent AND in a terminal condition (and it is the physician's responsibility to determine when a terminal condition exists), the hospital ethics committee, which is usually represented by a nun or a priest theologian, misrepresents Catholic medical-moral teaching to the family, convincing them that it is they and ONLY they who determine what is ordinary or extraordinary, regardless of the physician's opinion or prognosis. They then advise the family to transfer the patient's care to another physician who will carry out their wishes (usually one who is not Catholic and who believes in at least passive euthanasia and thus has no respect for the Church's teaching on ordinary vs. extraordinary means). Once the transfer is made, even the intravenous fluids are removed and the patient is given a morphine drip in rapidly increasing doses, resulting in death within 24 to 48 hours thereafter.

Another typical example is a patient who has the diagnosis of incurable cancer, but is not yet terminal, and the prognosis is still reasonably good for an extended period of time, perhaps 6 months to a year, or longer. When such a patient develops an infectious pneumonia or congestive heart failure which are treatable and reversible but may require a ventilator for a short period of time, permission for a ventilator is denied by the family NOT based on the reasoning that the patient will die "in spite" of the ventilator (in which case the ventilator would truly be an extraordinary treatment), but on the reasoning that if the patient recovers, he will have to face suffering and death from the cancer in the future, and thus it is better to allow him to die now. Again the theologian representing the ethics committee concurs with the family's reasoning, and justifies it based on an improper interpretation of the concept of "extraordinary" treatment. Empowered by the opinion of the theologian who is a Catholic priest or a Catholic nun, the family is erroneously led to believe that their decisions are in accordance with the Magisterium of the Church, and proceed with a "clear" conscience! Again, the patient is transferred to another attending physician, and a morphine drip is instituted to alleviate the patient's shortness of breath, and death ensues in a short period of time.

Attempts to ask the Archdiocesan authorities to intervene have so far been unsuccessful, because the Hospital is owned by the religious order which is independent of the local Ordinary, and it is determined that the Bishop does not have authority over the religious order, or whom they appoint to the institutional ethics committees.

It is of particular interest to point out that the ethics committee typically condones withdrawal of treatment on the basis of patient autonomy (disregarding the physician's medical opinion as a matter of principle), but when the opposite happens, that is, the family wishes to continue treatment against the advice of the physician, the ethics committee then sides with the physician, attempting to convince the family of the futility of further treatment, and the acceptability of treatment withdrawal. It appears to be the proverbial "one way street", to use an American idiom.

Father Peter A. Clark, a Jesuit priest and one of the ethicists at Mercy Health System, has co-authored an article in the July-August 2000 issue of "Health Progress", which is the official journal of the Catholic Health Association of the United States, which itself, like many Catholic hospitals, is completely independent of the Bishops of the United States. This article, named "Time for a Formalized Medical Futility Policy" is excellently critiqued and refuted by Wesley J. Smith under the title "Not-So-Catholic Bioethics" in the winter, 2001 edition of the "Human Life Review", an independent pro-life publication. Wesley Smith is also the author of a landmark book, "Culture of Death, the Assault on Medical Ethics in America". Author Smith states: "Futile-care policies directly contradict Catholic moral teaching concerning end-of-life care. Indeed, the Bishops identify 'omissions' that are intended to cause a form of euthanasia, an act unequivocally forbidden by Catholic moral teaching...To get around this snag, the authors [i.e. Clark] equate the treatments in question with the Catholic concept of "extraordinary care..."

Has my experience in my Catholic hospital been unique because of this one dissident theologian, or is this dangerous trend of cloaking euthanasia under the false interpretation of withdrawal of "extraordinary" care common in other Catholic hospitals? Unfortunately, I am convinced that this trend is widespread throughout Catholic hospitals, since most of the teaching materials for Catholic hospital ethics committees come from the Catholic Health Association, whose leading ethicist, Father Kevin O'Rourke, is well known for promoting the withdrawal of food and water from patients who are in a prolonged state of diminished consciousness.

This trend towards euthanasia in Catholic institutions also has a false theological basis rooted in false understanding of Church teaching about the nature of death and the nature of life after death. It is rooted in the heretical rejection of the possibility of suffering AFTER death, thus resulting in the false belief that death represents relief of all suffering. I believe that the basis of the Church's strong condemnation of ALL EUTHANASIA is precisely based on the certain knowledge, through Faith, that death is NOT necessarily the end of all suffering, and that eternal life is NOT inevitably achieved by death, but requires forgiveness of sins and the atonement for sin through the acceptance of our own suffering (either before or after death) in union with the Redemptive Suffering, Death and Resurrection of Our Lord Jesus Christ. Thus it is not death which ends suffering, but rather the Mystery of Redemption.

Author Wesley Smith concludes: "Church leaders have been sound in promulgating Catholic doctrine on medical ethics but slow to recognize the threat from within. They must now act swiftly and diligently, to the point, if necessary, of prohibiting renegade institutions from using the word "Catholic" in their names. There is still time to preserve the concept of sanctity of life, with all that that implies. But if the fifth column is not rooted out, its penetration of Catholic institutions will continue, and before we know what happened the new medicine will rule triumphant."

In my opinion, it is time to apply the lessons learned from Catholic universities in the battle to reestablish orthodoxy known as "Ex Corde Ecclesiae". A similar program must be initiated by the Church in Rome and by the national bishops' conferences and applied to Catholic health care institutions. All theologians who serve on ethics committees in Catholic hospitals must be approved and certified by the bishops in order to be in conformity with the Magisterium of the Church.


1. Declaration on Euthanasia, Sacred Congregation for the Doctrine of the Faith, Rome, 5/5/1980.

2. Ethical and Religious Directives for Catholic Health Care Services, Fourth Edition, United States Conference of Catholic Bishops, 6/15/2001

3. Wesley J. Smith, Culture of Death: The Assault on Medical Ethics in America, Encounter Books, San Francisco, California, 2000

4. Wesley J. Smith, "Not-So-Catholic Bioethics", Human Life Review, vol. XXVII, No. 1, published by the Human Life Foundation, New York, New York.

5. General Assembly of Pennsylvania, Senate Bill No.3, Session of 1991, as amended April 6, 1992, "The Pennsylvania Advance Directive for Health Care", published in Pennsylvania Medicine, vol. 88, August

Related Statement
Taking a stand against causing death, March 2,2005

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