GENERAL POLICY ON THE USE OF LIFE-SUSTAINING TREATMENTS

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.