The practices of physician assisted suicide (medical aid in dying) and euthanasia are being increasingly accepted throughout the world. This acceptance is becoming all too obvious. But both practices involve an action or omission which of itself or by intention causes death. And the Church has declared that these practices are always immoral.
Some people contend that the Church is hypocritical in her stance. They say that she does permit decisions to forego some medical interventions at the end of life. They argue this is equivalent to “passive euthanasia.” As such, they say, the Church should also accept other forms of euthanasia and physician assisted suicide. However, this opinion is a failure to understand the Church’s teachings on end of life care. It also disregards the significant distinctions she makes.
The Church’s Teachings on End of Life Care
When evaluating approaches to end of life care some take a ‘vitalistic stance.’ They say everything possible should be done, regardless of cost, to sustain and preserve bodily health and life. Others take a ‘relativistic view.’ This relativistic view says each individual can live as he/she pleases. As such, people should be able to freely choose to end life whenever they desire to do so. The Church does not hold to either extreme position.
Catholic teaching is that all life is sacred. All life is worthy of the utmost dignity and must be protected from conception to natural death. The Church further teaches there is a moral obligation “to care for oneself and to allow oneself to be cared for” (Evangelium vitae, 65), and “to use ordinary or proportionate means of preserving his or her life” (Ethical and Religious Directives for Catholic Health Care Services, 56). However, she acknowledges there can be medical interventions that are considered ‘disproportionate care.’ Such interventions are morally optional. As such they are not morally obligatory.
Proportionate and Disproportionate Care
The Church makes a distinction between proportionate (ordinary) care and disproportionate (extraordinary) care. In the Ethical and Religious Directives for Catholic Health Care Services (ERDS), the Church defines these terms:
“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…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 (56-57).”
With treatments, the degree of benefit varies depending on many factors. But we do not call something “disproportionate care” simply because the result will not be restoration of full, vigorous health or normal quality of life. As an example, amputation of a leg due to an infection will leave one less mobile and in need of either a prosthetic or a means to assist walking. But this intervention is not automatically disproportionate due to the acquired disability. It could be disproportionate care, but it could also be proportionate. With modern medicine, there is often a good success with these surgeries in a healthy young person.
In such decisions, no one should ever approach a situation with the view that a life is not worth living or has no value. Life itself is intrinsically good and is a great gift. All human life is sacred regardless of age, ability, intelligence, awareness or physical health. We cannot forget that any action or omission that is a direct attack on human life is immoral and cannot be justified.
Some Worldly Approaches to End of Life Decisions
Many people do not fully understand the depths of the Church’s moral teachings. This lack of understanding can lead to minimizing distinctions or even seeing them as absurd.
Many today attempt to judge the morality or immorality of actions based on intentions (Intentionalism). Irene Alexander, PhD, assistant professor of theology at the University of Dallas in Irving, Texas, defined Intentionalism in an article in the Autumn 2017 issue of The National Catholic Bioethics Quarterly. Essentially, if my intention or motive is good then this justifies whatever action I take. As an example, if my intent is to end a person’s suffering (which is a good), then how I accomplish this does not affect the morality of my actions. If I directly kill the person at their request, or omit interventions that would keep them alive, my intention is still good.
Others use the consequences of actions as the basis for judgment (Consequentialism). If the consequence of my action is good, this outweighs the immorality of my action and makes the act permissible. A related approach is Proportionalism. This is the view that holds that an evil action can be justified if the good that results outweighs the evil.
The Church opposes all these approaches.
We Must Make Judgments about the Morality of Care
To make judgments on the morality of medical interventions, we must consider the object, intention, and circumstances, just as we do with all human actions.
The ‘object’ we evaluate with end of life care is the treatment or intervention itself. Is the action intrinsically evil (immoral)? If it is, we are not permitted to take the action. We cannot attempt to justify it with good intentions or by arguing that the act is for the greater good. We are not to do an evil so that good may come from it. As Scripture tells us, the ends do not justify the means (Romans 3:8).
We must also assess the ‘intention’ of the patient. Why is this decision about treatment being made? What is the end goal of the action? If the reason is immoral, the action cannot be done.
Considering the Circumstances
Lastly, we evaluate the ‘circumstances.’ As the Catechism of the Catholic Church explains:
“The circumstances, including the consequences, are secondary elements of a moral act. They contribute to increasing or diminishing the moral goodness or evil of human acts … They can also diminish or increase the agent’s responsibility … Circumstances of themselves cannot change the moral quality of acts themselves; they can make neither good nor right and action that is in itself evil (1754).”
The circumstances to consider in medical cases are numerous. They include the complexity and risks of the intervention, along with the anticipated results. But they must also include the cost compared to the patient’s resources, standard of care versus experimental procedures, and the burdens of the treatment for the patient and family. It is also important to consider whether, in the judgment of the patient, the intervention offers a reasonable hope of benefit. These factors vary between individual patients and can change over time in a specific patient, so the situation must be often reassessed.
Considering the circumstances of medical interventions helps us to determine if the intervention is considered proportionate or disproportionate. Proportionate (or ordinary) care must always be done. But as Pope St. John Paul II wrote in Evangelium vitae (EV), “To forego extraordinary or disproportionate means is not the equivalent of suicide or euthanasia; it rather expresses acceptance of the human condition in the face of death” (65).
Discontinuing Medical Care
It is impossible to give a list of treatments considered disproportionate versus proportionate because it is necessary to evaluate the patient’s circumstances as a whole. But before we act, it is first critical we ensure both the object and the intention is moral.
If the result of an intervention will directly kill the person, it is intrinsically evil. If our intention is to end the life of the person (if death is willed or sought), the act (or omission) is immoral. But if both the intervention and the intention are moral, then we must assess the circumstances and determine what would be proportionate and disproportionate care.
Critics claim if we discontinue interventions deemed disproportionate, knowing that the consequence will be the death of the person, this is no different than a physician acting to directly end the life of the patient. But this is not true. If the intention is to cause death, whether an action is done or omitted, it is immoral. It is a direct attack on life. No circumstance, noble intention or good outcome justifies immoral actions. The ends do not justify the means.
Discontinuing Disproportionate Treatments
But if medical treatments judged to be disproportionate are discontinued, and our intention is not to directly end the person’s life by what we do or do not do, we are only accepting the human condition. We are letting nature take its course. This is not a direct attack on life. It is the legitimate refusal of interventions deemed optional and seen as entailing excessive burden with no reasonable hope of benefit. However, when treatments are discontinued, it is still obligatory to continue all ordinary and proportionate care until the person dies naturally.
The Catechism of the Catholic Church explains:
” … an act or omission which, of itself or by intention, causes death in order to eliminate suffering constitutes a murder gravely contrary to the dignity of the human person and to the respect due to the living God, his Creator. The error of judgment into which one can fall in good faith does not change the nature of this murderous act, which must always be forbidden and excluded.
“Discontinuing medical procedures that are burdensome, dangerous, extraordinary or disproportionate to the expected outcome can be legitimate; it is the refusal of “over-zealous” treatment. Here one does not will to cause death; one’s inability to impede it is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected.
“Even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted. (2277-2279)”
End of Life Decisions are Complex
End of life decisions can be very complicated. Many people are quick to try to rationalize actions, so, as Catholics, we must be cautious. It is important to ensure Catholic principles are properly applied. We must also try to be more knowledgeable on the moral teachings of the Church. Ultimately, we should not hesitate to involve a priest, moral theologian or Catholic bioethicist in end of life situations.