Bioethics and End-of-Life Issues

ZenitZenit, 30 april 2013
by Peter Waymel

In the context of a widespread prevailing medical and social praxis that endanger that value of life perennially defended by the Catholic Church, it can be useful to offer some reflections on end-of-life issues, specifically on the difference between refusing extraordinary measures and suicide (both doctor-assisted and ‘autonomous’).

A convention held recently at the Pontifical Lateran University in Rome on bioethics and end-of-life issues highlighted a number of fields where the Catholic perspective is in sharp conflict with either current medical practice, and trends threatening to go beyond de facto practice silently occurring between doctor, patient, and relatives in hospitals across the world, to become legislated practices, endorsed by law. One such field merits perhaps special attention, due to the likelihood that a given individual is to come across such a situation in the course of his or her life: the moral question regarding the refusal of possibly life-extending treatment, and the ensuing questions of whether this constitutes suicide, or differs moreover from the refusal of food and water.

In the issue of end-of-life practices, Fr. Maurizio Faggioni, O.F.M., professor of moral theology and bioethics at the Pontifical University “Antonianum” in Rome, affirmed that currently there is a distinction that needs to be made between assisted suicide and a refusing life-extending therapeutic measures. Are both to be considered suicide? The conclusion was drawn that refusing therapeutic measures that prove futile (they will not help the patient recover), burdensome (they constitute an unnecessary pain for the patient undergoing treatment), and economically expensive (so that the patient’s family or hospital undergoes an enormous financial burden for a measure unlikely to help the patient) are areas where a patient with a terminal illness can, with an upright moral conscience, either request for a medical treatment they are currently undergoing to be withdrawn from them, or can, with equal moral tranquillity, refuse a suggested measure that might prolong their life for a modicum of time. Even in cases where their life could be prolonged for longer than a mere span of days or weeks, Prof. Faggioni’s argued that there is no ethical obligation upon the patient (or upon the patient’s family, where the patient is in coma), to continue or accept a life-extending measure that would place great physical pain upon the patient or undue financial burden upon the patient (or those responsible for his or her care).

One grey area that results from this inquiry, and that has to our knowledge not been addressed by either Catholic moral teaching or legislation, is the question of what exactly constitutes an undue economic burden upon the family or the terminal patient.

Why is this different from suicide?
The aforementioned choice to refuse a possibly life-extending treatment differs from suicide inasmuch as the patient is not actively seeking their death, or undertaking artificial means to provoke it. The patient is, rather, accepting a natural process that has begun in them (dying). The personal choice to refuse possibly life-extending measures was made in 2005 by no less than John Paul II; who chose finally not to be rushed to Gemelli hospital again, where he could have received, dialysis to help his renal failure, a pump to assist circulation, and a ventilator to assist his breathing. It seems the Holy Father acknowledged the by-then far-advanced process of dying that was naturally taking its course in him, was conscious of the extreme pain that such interventions – which, Prof. Faggiani recalled to attendees of the Lateran seminar, are always accompanied by some, and often great, pain – and chose to acquiesce to the Father’s will to bring his earthly pilgrimage to a close, rather than fight a process which was both natural and manifestly taking its course in his body.

Who can refuse such treatment?
One specification, however, is necessary: it is always the patient who retains the right to refuse such measures; while the patient is conscious, the decision to withdraw or withhold life-extending measures cannot be made by family members or the doctor.

Is this the same as refusing food and water?
One further clarification: possibly futile, certainly financially onerous or unduly painful life-extending measures are not to be confused with food and water (feeding tubes): both Catholic moral teaching and, at present, the Constitution of (at least) the Italian State concord in identifying normal nutrition as being well within the routine care which every individual both has a right to and would be wrong to refuse.

The Vatican released a statement in 2007 affirming that feeding tubes are not medical therapy and cannot be withheld from a permanently unconscious person. This same was reiterated by Pope John Paul II a few days later, when he announced that artificial food and water is always “morally obligatory” and removing a feeding tube is “true euthanasia by omission,” violating God’s law. Such refusal by an individual to personal nourishment and hydration could constitute suicide except in the limit case in which the assumption of food or water causes such pain that it, too, could be considered an undue physical burden to the patient.

This latter case, however, opens a grey area in current legislature, inasmuch as the mental, or psychological state (and therefore, possible suffering) of the individual is not known to doctor’s or family members, when such an individual is in coma or a vegetative state. In this vein, thus, proponents of a purported “right to die” of persons in coma or vegetative states have argued that such persons could be in great suffering, and thus would wish for their lives to be ended, through the removal of respirators and the withdrawal of ordinary nourishment (this was the case of Eluano Englaro in Italy in 2009). In this case, though the Constitution upholds the right to the individual to food and water during coma, the Italian Supreme Court (Corte della Cassazione) ruled that both forms of nourishment could be taken from the girl, as long as the twofold condition that the patient have expressed such a desire even marginally, in some previous time in their life (“that such a request [i.e., to suspend food and water] truly express the will of the patient, deduced from their preceding affirmations, or their personality, or their lifestyle and convictions”) and that the coma or vegetative state be truly irreversible, that is, that a rigorous medical analysis show that there is no hope of an even minimal recovery of consciousness in the future. (Inasmuch as rare cases have defied even the most certain of medical prognosis, showing a person in coma to return to some form of consciousness, albeit often a reduced one, it is hazardous, perhaps, for Italian jurisprudence to emit such a sentence).

Given a moral climate which sees lawmakers and magistrates alike, as well as ordinary citizens, it seems, increasingly willing to reduce the periods of life in which life itself is considered sacred, it is well for Catholics of conscience to be well informed on moral, end-of-life issues. Further reference for these matters can be found in the teachings of John Paul II, Evangelium vitae, Veritatis splendour, and the Catechism of the Catholic Church.

On an academic level, the Lateran convention represented one of various recent and upcoming events aimed at addressing the dangerous moral ground on which patients, Catholics, and legislators seem to tread in the current social and political climate in Italy and Europe as a whole.

An upcoming follow-up to the convention, to be held at the Catholic University of Piacenza (May 25-27, to host, among other speakers, world-renowned neuroscientist Walter Freeman, professor emeritus at the University of California at Berkeley, and Nobel Peace prize winner in Medicine, Luc Montagnier) will contribute to the discussion on bioethics and Catholic teaching; the findings of the latter encounter will result in the publication of acts, for scholarly reference, also involving those matters in bioethics where either prevailing social practice or matters currently being tested in Italian and European jurisprudence are at odds with Catholic moral teaching.