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?
NOTES
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."
Related
Statement
Taking
a stand against causing death, March
2,2005
