Irving Response to Daly

“Massive Confusion Re Church Teachings
on Euthanasia by Pastors”

 

Dr. Dianne N. Irving, M.A., Ph.D.
November 6, 2003

DNIrving@aol.com

Dr. Irving’s professional activities include teaching positions at Georgetown University, Catholic University of America, and The Dominican House of Studies. She represented the Catholic Medical Association of the United States, and the International Federation of Catholic Medical Associations, at the Scientific Conference in Mexico City, Mexico, October 28, 1999 and presented a paper on “The Dignity and Status of the Human Embryo”. Dr. Irving is a former career-appointed bench research biochemist/biologist (NIH, NCI, Bethesda, MD), an M.A. and Ph.D. philosopher (Georgetown University, Washington, D.C.), and Professor of the History of Philosophy, and of Medical Ethics.

At this point in the Terri Schiavo case, most people remain very confused as to what the official teachings of the Catholic Church really are with regard to euthanasia.  Compounding this problem has been previous questionable testimony by Fr. Murphy misrepresenting the Church’s teachings before the Florida court (please see an extensive and sophisticated refutation of Fr. Murphy’s testimony by Catholic theologians Dolan and Flattery athttp://www.terrisfight.org/Framesets/RecentFrame.htm  before the Schiavo court.)

Now we have perhaps misguided inserts appearing in parish Sunday bulletins on this case (See for example: Letting Go and Letting God…Letting Terri Schiavo go to God) quoting “Church teachings” supporting the removal of food and hydration from Terri Schiavo, further confusing both laity and clergy alike.  However, such bulletin inserts contain only selective paragraphs from what is in fact simply an unofficial “reflection” paper on the official website for the NCCB, (currently USCCB) and omit any mention of the official USCCB directives and the official website where they can be found — i.e., the U.S. Catholic Conference of Bishops’ Ethical and Religious Directives for Health Care Services — directives which would counter the conclusions in the parish bulletin insert.  Even many significant paragraphs in that unofficial “reflection paper” that are selectively omitted in the parish bulletin insert would counter the conclusions in the bulletin insert itself.  Nor are any of the traditional Church teachings on euthanasia, or where to find them, provided for the laity.

As theologians Dolan and Flattery pointed out in their testimony, the existence of disagreements among theologians on a specific issue are not uncommon, but they do not substitute for official Church teachings on euthanasia, which traditional teachings are abundantly available.  (See, e.g., the Declaration on Euthanasia at http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19800505_euthanasia_en.html as well as the Charter for Health Care Workers at:

 http://www.vatican.va/roman_curia/pontifical_councils/hlthwork/documents/rc_pc_hlthwork_doc_19950101_charter_en.html?GRAB_ID=2\&EXTRA_ARG=\&HOST_ID=42\&PAGE_ID=3940608.

Given that several elements in this unofficial “reflection paper” might be erroneous or misguided themselves, I hesitate to even copy it here.  Yet, I do so for two reasons.  First, it is essential to carry out as extensive as possible dialogues on these difficult issues, and this unofficial “reflection paper” cited in the parish bulletin insert is one small attempt to do so.  Obviously, far more “reflections” and clarifications are needed and welcome on the unofficial level.  Yet the official Church teachings on euthanasia are clear, extensive and available, and it seems to me for Catholics should be the “teachings” that are to be applied to the Schiavo case.  Second, I wish to point out that onlycertain sections of that “reflection paper” are included in the parish bulletin insert, and those paragraphs that were omitted are significant and should also be provided for the laity for their further education on these issues.  These “omitted” paragraphs are provided below.  Yet fundamentally, we should begin our own “education” by first reading the official teachings of the USCCB and of the Church, before moving to “reflection papers” and individual “theories” of individual theologians, and those websites are provided below.  This way hopefully we should be able to know the difference between what is an unofficial “reflection paper” or idiosyncratic “theological theory” and an official teaching of the Church on euthanasia.

This message is thus an attempt to begin the clarification process.  For those interested, the URL’s for specific websites containing the official USCCB document are provided below for your further research.  The problematic fullpastoral bulletin insert may be accessed here.  The websites for the official Church teachings are cited above.  Thus what follows are:
(1) the official USCCB directives for euthanasia, and
(2) those paragraphs from the unofficial “reflection paper” which were omitted from the parish bulletin insert but which should also be available to the laity.  Note particularly the “Conclusion” section of this unofficial “reflection paper”, which itself is in concert with the official teachings of the USCCB on the issue of food and hydration.  Finally, it is of interest to note that one of the footnotes in the intact NCCB “reflection paper” is a reference for Dr. Ron Cranford, long time bioethicist who has been favoring euthanasia and actively promoting physician assisted suicide for decades, and who also testified for the Schiavo husband before the Florida court in favor of removing Terri’s feeding tube.

Terri, a Catholic woman, is seriously disabled.  But she is not in a PVS (Persistent Vegetative State), she is not terminal or dying, she is not in pain or suffering. Food and hydration for her would be “ordinary means” (palliative care).  Affidavits from expert medical doctors agree her condition could be improved. She left no written directives, there are massive conflicts of interests involved and allegations of abuse that need to be investigated, and when in doubt we should err on the side of life.  Keeping in mind the extensive misinformation concerning the medical and legal facts of the Schiavo case that are already “out there”, it is hoped that the following facts might at least help to begin the clarification process concerning what the official teachings of the Church are on euthanasia, the removal of food and hydration, etc., and then apply these facts to the Schiavo case itself.


(EMPHASIS ADDED AS NOTED IN BOLD; ANNOTATION NOTES IN RED BRACKET)

OFFICIAL USCCB DOCUMENT CONTAINING DIRECTIVES ON EUTHANASIA:

http://www.usccb.org/bishops/directives.htm
Ethical and Religious Directives for Catholic Health Care Services,
Fourth Edition
United States Conference of Catholic Bishops
Issued by NCCB/USCC, June 15, 2001
Copyright © 2001, United States Conference of Catholic Bishops, Inc. All rights reserved.

http://www.usccb.org/bishops/directives.htm#partfive

Suicide and euthanasia are never morally acceptable options.

Some state Catholic conferences, individual bishops, and the USCCB Committee on Pro-Life Activities (formerly an NCCB committee) have addressed the moral issues concerning medically assisted hydration and nutrition. The bishops are guided by the Church’s teaching forbidding euthanasia, which is “an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated.”38 These statements agree that hydration and nutrition are not morally obligatory either when they bring no comfort to a person who is imminently dying or when they cannot be assimilated by a person’s body.

Directives 

55. Catholic health care institutions offering care to persons in danger of death from illness, accident, advanced age, or similar condition should provide them with appropriate opportunities to prepare for death. Persons in danger of death should be provided with whatever information is necessary to help them understand their condition and have the opportunity to discuss their condition with their family members and care providers. They should also be offered the appropriate medical information that would make it possible to address the morally legitimate choices available to them. They should be provided the spiritual support as well as the opportunity to receive the sacraments in order to prepare well for death.

56. 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. [ftnt 40]

57. 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. [ftnt 41]

58. There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient.

59. 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.

60. Euthanasia is an action or omission that of itself or by intention causes death in order to alleviate suffering. Catholic health care institutions may never condone or participate in euthanasia or assisted suicide in any way. Dying patients who request euthanasia should receive loving care, psychological and spiritual support, and appropriate remedies for pain and other symptoms so that they can live with dignity until the time of natural death. [ftnt 42]

61. Patients should be kept as free of pain as possible so that they may die comfortably and with dignity, and in the place where they wish to die. Since a person has the right to prepare for his or her death while fully conscious, he or she should not be deprived of consciousness without a compelling reason. Medicines capable of alleviating or suppressing pain may be given to a dying person, even if this therapy may indirectly shorten the person’s life so long as the intent is not to hasten death. Patients experiencing suffering that cannot be alleviated should be helped to appreciate the Christian understanding of redemptive suffering.

62. The determination of death should be made by the physician or competent medical authority in accordance with responsible and commonly accepted scientific criteria.

63. Catholic health care institutions should encourage and provide the means whereby those who wish to do so may arrange for the donation of their organs and bodily tissue, for ethically legitimate purposes, so that they may be used for donation and research after death.

64. Such organs should not be removed until it has been medically determined that the patient has died. In order to prevent any conflict of interest, the physician who determines death should not be a member of the transplant team.

65. Use of tissue or organs from an infant may be permitted after death has been determined and with the informed consent of the parents or guardians.

66. Catholic health care institutions should not make use of human tissue obtained by direct abortions even for research and therapeutic purposes. [ftnt 43]


PARAGRAPHS FROM THE UNOFFICIAL “REFLECTION PAPER” OMITTED FROM THE PARISH BULLETIN INSERT:

http://www.usccb.org/prolife/issues/euthanas/nutindex.htm

Nutrition and Hydration: Moral and Pastoral Reflections (1992) Resource Paper
NCCB Committee for Pro-Life Activites

(Table of Contents)
—  Introduction http://www.usccb.org/prolife/issues/euthanas/nutintro.htm

—  Moral Principles http://www.usccb.org/prolife/issues/euthanas/nutmoral.htm

—  Questions About Medically-Assisted Nutrition and Hydration http://www.usccb.org/prolife/issues/euthanas/nutqa.htm  [This is the only part of this “reflection paper” included in the pastoral bulletin insert;  omitted paragraphs are copied below]

—  Conclusion http://www.usccb.org/prolife/issues/euthanas/nutconc.htm

—  Appendix: Technical Aspects of Medically-Assisted Nutrition and Hydration http://www.usccb.org/prolife/issues/euthanas/nutend.htm

http://www.usccb.org/prolife/issues/euthanas/nutqa.htm
Questions about Medically Assisted
Nutrition and Hydration

The following important and significant paragraphs of this section were left out of the “pastoral letter”:

In what follows we apply these well-established moral principles  to the difficult issue of providing medically assisted nutrition and hydration to persons who are seriously ill, disabled or persistently unconsciousWe recognize the complexity involved in applying these principles to individual cases and acknowledge that, at this time and on this particular issue, our applications do not have the same authority as the principles themselves.

1. Is the withholding or withdrawing of medically assisted nutrition and hydration always a direct killing?
In answering this question one should avoid two extremes.

First, it is wrong to say that this could not be a matter of killing simply because it involves an omission rather than a positive action. In fact a deliberate omission may be an effective and certain way to kill, especially to kill someone weakened by illness. Catholic teaching condemns as euthanasia “an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated.” Thus “euthanasia includes not only active mercy killing but also the omission of treatment when the purpose of the omission is to kill the patient.”[11]

Second, we should not assume that all or most decisions to withhold or withdraw medically assisted nutrition and hydration are attempts to cause death. To be sure, any patient will die if all nutrition and hydration are withheld.[12] But sometimes other causes are at work — for example, the patient may be imminently dying, whether feeding takes place or not, from an already existing terminal condition. At other times, although the shortening of the patient’s life is one foreseeable result of an omission, the real purpose of the omission was to relieve the patient of a particular procedure that was of limited usefulness to the patient or unreasonably burdensome for the patient and the patient’s family or caregivers. This kind of decision should not be equated with a decision to kill or with suicide.

The harsh reality is that some who propose withdrawal of nutrition and hydration from certain patients do directly intend to bring about a patient’s death, and would even prefer a change in the law to allow for what they see as more “quick and painless” means to cause death.[13] In other words, nutrition and hydration (whether orally administered or medically assisted) are sometimes withdrawn not because a patient is dying, but precisely because a patient is not dying (or not dying quickly) and someone believes it would be better if he or she did, generally because the patient is perceived as having an unacceptably low “quality of life” or as imposing burdens on others.[14]

When deciding whether to withhold or withdraw medically assisted nutrition and hydration, or other forms of life support, we are called by our moral tradition to ask ourselves: What will my decision do for this patient? And what am I trying to achieve by doing it? We must be sure that it is not our intent to cause the patient’s death — either for its own sake or as a means to achieving some other goal such as the relief of suffering.

2. Is medically assisted nutrition and hydration a form of “treatment” or “care”?
Catholic teaching provides that a person in the final stages of dying need not accept “forms of treatment that would only secure a precarious and burdensome prolongation of life,” but should still receive “the normal care due to the sick person in similar cases.”[15] All patients deserve to receive normal care out of respect for their inherent dignity as persons. As Pope John Paul II has said, a decision to forgo “purely experimental or ineffective interventions” does not “dispense from the valid therapeutic task of sustaining life or from assistance with the normal means of sustaining life. Science, even when it is unable to heal, can and should care for and assist the sick.”[16] But the teaching of the Church has not resolved the question whether medically assisted nutrition and hydration should always be seen as a form of normal care.[17] [Refuted extensively by testimony provided by expert Catholic theologians in refuting Fr. Murphy’s erroneous testimony before the Schiavo court http://www.terrisfight.org/Framesets/RecentFrame.htm  

Almost everyone agrees that oral feeding, when it can be accepted and assimilated by a patient, is a form of care owed to all helpless people. Christians should be especially sensitive to this obligation, because giving food and drink to those in need is an important expression of Christian love and concern (Mt. 10:42 and 25:35; Mk. 9:41). But our obligations become less clear when adequate nutrition and hydration require the skills of trained medical personnel and the use of technologies that may be perceived as very burdensome — that is, as intrusive, painful or repugnant. Such factors vary from one type of feeding procedure to another, and from one patient to another, making it difficult to classify all feeding procedures as either “care” or “treatment.”

Perhaps this dilemma should be viewed in a broader context. Even medical “treatments” are morally obligatory when they are “ordinary” means–that is, if they provide a reasonable hope of benefit and do not involve excessive burdens. Therefore we believe people should make decisions in light of a simple and fundamental insight: Out of respect for the dignity of the human person, we are obliged to preserve our own lives, and help others preserve theirs, by the use of means that have a reasonable hope of sustaining life without imposing unreasonable burdens on those we seek to help, that is, on the patient and his or her family and community. We must therefore address the question of benefits and burdens next, recognizing that a full moral analysis is only possible when one knows the effects of a given procedure on a particular patient.

Economic and other burdens on caregivers
While some balk at the idea, in principle cost can be a valid factor in decisions about life support. For example, money spent on expensive treatment for one family member may be money otherwise needed for food, housing and other necessities for the rest of the family. Here, also, we offer some cautions.

First, particularly when a form of treatment “carries a risk or is burdensome” on other grounds, a critically ill person may have a legitimate and altruistic desire “not to impose excessive expense on the family or the community.”[25]Even for altruistic reasons a patient should not directly intend his or her own death by malnutrition or dehydration, but may accept an earlier death as a consequence of his or her refusal of an unreasonably expensive treatment. Decisions by others to deny an incompetent patient medically assisted nutrition and hydration for reasons of cost raise additional concerns about justice to the individual patient, who could wrongly be deprived of life itself to serve the less fundamental needs of others.

Second, we do not think individual decisions about medically assisted nutrition and hydration should be determined by macro-economic concerns such as national budget priorities and the high cost of health care. These social problems are serious, but it is by no means established that they require depriving chronically ill and helpless patients of effective and easily tolerated measures that they need to survive. [26]

Third, tube feeding alone is generally not very expensive and may cost no more than oral feeding.[27] What is seen by many as a grave financial and emotional burden on caregivers is the total long-term care of severely debilitated patients, who may survive for many years with no life support except medically assisted nutrition and hydration and nursing care.

The difficulties families may face in this regard, and their need for improved financial and other assistance from the rest of society, should not be underestimated. While caring for a helpless loved one can provide many intangible benefits to family members and bring them closer together, the responsibilities of care can also strain even close and loving family relationships; complex medical decisions must be made under emotionally difficult circumstances not easily appreciated by those who have never faced such situations.

Even here, however, we must try to think through carefully what we intend by withdrawing medically assisted nutrition and hydration. Are we deliberately trying to make sure that the patient dies, in order to relieve caregivers of the financial and emotional burdens that will fall upon them if the patient survives? Are we really implementing a decision to withdraw all other forms of care, precisely because the patient offers so little response to the efforts of caregivers? Decisions like these seem to reach beyond the weighing of burdens and benefits of medically assisted nutrition and hydration as such.

In the context of official Church teaching, it is not yet clear to what extent we may assess the burden of a patient’s total care rather than the burden of a particular treatment when we seek to refuse “burdensome” life support. 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?

Rather than leaving families to confront such dilemmas alone, society and government should improve their assistance to families whose financial and emotional resources are strained by long-term care of loved ones.[28]

3. What role should “quality of life” play in our decisions?
Financial and emotional burdens are willingly endured by most families to raise their children or to care for mentally aware but weak and elderly family members. It is sometimes argued that we need not endure comparable burdens to feed and care for persons with severe mental and physical disabilities, because their low “quality of life” makes it unnecessary or pointless to preserve their lives.[29]

But this argument — even when it seems motivated by a humanitarian concern to reduce suffering and hardship — ignores the equal dignity and sanctity of all human life. Its key assumption — that people with disabilities necessarily enjoy life less than others or lack the potential to lead meaningful lives — is also mistaken.[30] Where suffering does exist, society’s response should not be to neglect or eliminate the lives of people with disabilities, but to help correct their inadequate living conditions.[31] Very often the worst threat to a good “quality of life” for these people is not the disability itself, but the prejudicial attitudes of others–attitudes based on the idea that a life with serious disabilities is not worth living.[32]

This being said, our moral tradition allows for three ways in which the “quality of life” of a seriously ill patient is relevant to treatment decisions:
1. Consistent with respect for the inherent sanctity of life, we should relieve needless suffering and support morally acceptable ways of improving each patient’s quality of life.[33]
2. One may legitimately refuse a treatment because it would itself create an impairment imposing new serious burdens or risks on the patient. This decision to avoid the new burdens or risks created by a treatment is not the same as directly intending to end life in order to avoid the burden of living in a disabled state.[34]
3. Sometimes a disabling condition may directly influence the benefits and burdens of a specific treatment for a particular patient. For example, a confused or demented patient may find medically assisted nutrition and hydration more frightening and burdensome than other patients do because he or she cannot understand what it is. The patient may even repeatedly pull out feeding tubes, requiring burdensome physical restraints if this form of feeding is to be continued. In such cases, ways of alleviating such special burdens should be explored before concluding that they justify withholding all food and fluids needed to sustain life.

These humane considerations are quite different from a “quality of life” ethic that would judge individuals with disabilities or limited potential as not worthy of care or respect. It is one thing to withhold a procedure because it would impose new disabilities on a patient, and quite another thing to say that patients who already have such disabilities should not have their lives preserved. A means considered ordinary or proportionate for other patients should not be considered extraordinary or disproportionate for severely impaired patients solely because of a judgment that their lives are not worth living.

In short, while considerations regarding a person’s quality of life have some validity in weighing the burdens and benefits of medical treatment, at the present time in our society judgments about the quality of life are sometimes used to promote euthanasia. The Church must emphasize the sanctity of life of each person as a fundamental principle in all moral decisionmaking.

4. Do persistently unconscious patients represent a special case?
Even Catholics who accept the same basic moral principles may strongly disagree on how to apply them to patients who appear to be persistently unconscious — that is, those who are in a permanent coma or a “persistent vegetative state” (PVS).[35] Some moral questions in this area have not been explicitly resolved by the Church’s teaching authority.

Conclusion http://www.usccb.org/prolife/issues/euthanas/nutconc.htm

In this document we reaffirm moral principles that provide a basis for responsible discussion of the morality of life support. We also offer tentative guidance on how to apply these principles to the difficult issue of medically assisted nutrition and hydration. We reject any omission of nutrition and hydration intended to cause a patient’s death. 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. Recognizing that judgments about the benefits and burdens of medically assisted nutrition and hydration in individual cases have a subjective element and are generally best made by the patient directly involved, we also affirm a legitimate role for families’ love and guidance, health care professionals’ ethical concerns, and society’s interest in preserving life and protecting the helpless. In rejecting broadly permissive policies on withdrawal of nutrition and hydration from vulnerable patients, we must also help ensure that the burdens of caring for the helpless are more equitably shared throughout our society. We recognize that this document is our first word, not our last word, on some of the complex questions involved in this subject. We urge Catholics and others concerned about the dignity of the human person to study these reflections and participate in the continuing public discussion of how best to address the needs of the helpless in our society. 


FOOTNOTE REFERENCES FOR “REFLECTION PAPER”:
NOTE: NUMBERS COPIED INTO PARISH BULLETIN INSERT ACTUALLY REFER TO FOOTNOTE REFERENCES IN ORIGINAL NCCB “REFLECTION PAPER”, NOT TO OFFICIAL DIRECTIVE NUMBERS”

ftnt 18]. World Medical Association, Declaration of Helsinki (1975), II.1
.
[ftnt 19]. See Joyce V. Zerwekh, “The Dehydration Question,” Nursing83 (January 1983), pages 47-51.

[ftnt 20]. See William E. May et al., “Feeding and Hydrating the Permanently Unconscious and Other Vulnerable Persons,” Issues in Law and Medicine, Volume 2 (Winter 1987), page 208.

[ftnt 21]. Ronald E. Cranford, “The Persistent Vegetative State : The Medical Reality (Getting the Facts Straight), “Hastings Center Report, Volume 18 (February/March 1988), page 31. (emphasis added)

[ftnt 22]. Declaration on Euthanasia, Part IV.

[ftnt 23]. Current ethical guideline for nurses, while generally defending patient autonomy, reflect this concern: “Obligations to prevent harm and bring benefit . . . require that nurses seek to understand the patient’s reasons for refusal . . . Nurses should make every effort to correct inaccurate views, to modify superficially held beliefs and overly dramatic gestures, and to resotre hope where there is reason to hope.” American Nurses’ Association Committtee on Ethics, “Guideline on Withdrawing or Withholding Food and Fluid,” Biolaw, Volume 2 (October 1988), pages U1124-5.

[ftnt 24]. In one such study, “seventy percent of patients and families were 100% willing to undergo intensive care again to achieve even one month of survival”; “age, severity of critical illness, length of stay, and charges for intensive care did not influence willingness to undergo intensive care.” Danis et al., “Patients’ and Families’ Preferences for Medical Intensive Care,” Journal of the American Medical Association, Volume 260 (August 12, 1988), page 797. In another study, out of 33 people who had clse relatives in a “persistent vegetative state,” 29 agreed with the intial decision to initiate tube feeding and 25 strongly agreed that such feeding should be continued, although none of those surveyed had made the decision to initiate it. Tresch et al., “Patients in a Persistent Vegatative State : Attitudes and Reactions of Family Members,” Journal of the American Geriatrics Society, Vol. 39 (January 1991), pages 17-21.