The Catholic Intellectual Tradition and the Current Consensus about
Life-Sustaining Treatment
by Carol A. Tauer
Professor of Philosophy
October 29, 1996



A little over a year ago a student in my Biomedical Ethics class brought me an article from the New Yorker magazine that she wanted to share with the class. A memoir written by a journalist, is described a family’s desperate attempts to ease the dying of a loved one (Solomon). This family encountered resistance at every turn from medical establishment that refused to listen to them, that insisted on using every technology at their disposal, and that did not even provide adequate remedies for pain and suffering. Among other culprits, the author identified the Roman Catholic Church as the organized force behind what is called a "vitalist" philosophy: the belief that life itself is an absolute value and that it must be preserved by all means and whenever possible (Soloman, p. 59).
I was astounded to read this description of Catholic belief. It is not merely a caricature, but is almost 180 degrees the reverse of the Catholic tradition and its intellectual contribution to the debate on life-sustaining treatment.
True, the Catholic tradition does oppose direct killing or euthanasia of the terminally ill, and it does consistently argue against a supposed right to take one’s own life. But the Church has the intellectual tools and a history of centuries of scholarly debate and discussion that enable it to draw lines and to make careful distinctions. When the field of secular bioethics began to develop in the 1970s, its neophytes looked for principles that could guide their work- -and they found significant guidance within the Catholic tradition.
Basic Sources
What is this Catholic tradition based on? As with all Catholic moral teaching, it has two sources: The first source is human reason, as reason observes the world and figures out how it is good for human beings to live. What is our purpose as humans, and how can we reasonably achieve that purpose? The second source of Catholic teaching is revelation as found in the teachings of Christ, in Scripture in general, and in historical interpretations of this revelation.
Specifically, these two sources lead the believer to recognize that mere life itself is not an absolute good and is, in fact, not even the highest good; that death is not the greatest evil, to be avoided at all costs; and that we must use human reason to come to understand the difference between "a time to live and a time to die." Although St. Paul was not referring to a condition of terminal illness, Paul repeatedly made statements such as: "To live is Christ and to die is gain" (Phil. 1:21); "While we are at home in the body we are away from the Lord . . . . [but] we would rather be away from the body and at home with the Lord" (2 Cor. 5:7-8).
Historical Discussion
When we turn to the Catholic tradition’s efforts to apply these basic beliefs to the situation of the sick or dying person, we find that theologians for centuries sought a reasonable balance. On the one hand, a person was not morally permitted to bring about his or her own death, so a person had some responsibility to take care of life and health. On the other hand, a person was not required to take extreme measures to extend or prolong life, but could weigh other factors and responsibilities against proposed measures for extending life.
As early as the sixteenth century, Catholic moralists began to express this distinction in the terminology of ordinary and extraordinary means of treatment. Presumably extraordinary means were those extreme measures of prolonging life that one was not obligated to use.
During four centuries of discussion, up to the second half of the twentieth century, it is fascinating to see the differences of opinion that persisted in this discussion. Two well-respected theologians often specifically disagreed on a particular issue, while no ecclesiastical authority stepped in to say which was correct. Doctors and patients were allowed to act on the basis of the opinion that seemed most convincing and reasonable to them.
An amazingly wide range of factors was discussed by theologians (Kelly 1950; Kelly 1951; McCartney). Extraordinary means of treatment could include:
1) Leaving one’s family to move to a more healthful climate that would prolong life for a few extra years;
2) A surgical procedure that would save life but might involve intense pain (especially in pre-anesthetic days);
3) Amputation of a limb (even with anesthetic) is one had personal repugnance to living with a “mutilated” body;
4) Revulsion of a young woman at being treated by a male physician;
5) Excessive expense involved in treatment;
6) Uncertainty of a successful outcome.
Well-known theologians proposed these extenuating factors, among others- -while other theologians disagreed. For example, after surgical anesthetics became available, some theologians maintained that a life-saving limb amputation would now be morally obligatory. Others disagreed, arguing that the patient might find amputation of an arm or leg so repugnant that it would be an extraordinary means for that particular patient.
Several themes emerge from these discussions:
1) That the duty under consideration is the patient’s duty; that is, the patient is responsible for the choice.
2) That the patient’s choice (apart from unusual circumstances) must be respected: "One is one’s own master when it comes to parts of one’s own body" (McCartney, p. 216).
3) That ordinary and extraordinary means cannot be sorted into two neat categories of treatment, but they have to be considered relative to the patient’s condition. For example, intravenous fluids given to a person who will probably recover is morally different from IV’s for a person who is dying.
4) That subjective factors are pertinent. The patient’s own perception of the pain, suffering and mental anguish is part of the assessment.
5) That the fulfillment of other duties affects one’s responsibility to prolong life. For example, if a person is not spiritually prepared to die or has not resolved issues with family members, it may then be obligatory to extend life in order to take care of these matters. (From a sudden and unprovided death, O Lord, deliver us, we pray in the Litany of the Saints.)
6) That consciousness is significant because only a conscious person is able to fulfill responsibilities to God and to loved ones. Thus many theologians historically have argued that when a person is in “terminal coma,” there is no obligation to continue to use life-sustaining measures including artificial feeding. Gerald Kelly, S.J., who summarized the debate in 1950, says: "I see no reason why even the most delicate professional standard should call for their use. . . .The artificial means not only need not but should not be used. . . .Their use creates expense and nervous strain without conferring any real benefit" (Kelly 1990, p. 220).
In his articles in Theological Studies in 1950 and 1951, Kelly surveyed the tradition up to that time, and provided what has come to be accepted as a definitive statement: Kelly intended this definition to express a moral norm: While ordinary means are obligatory, extraordinary means are not, although they may be used (i.e., are optional).
Authoritative Pronouncement
Still no word from the Vatican? That was to change. In the latter 1950s, Pope Pius XII was often presented with specific questions from professional societies that were granted audiences with him. In 1957 he addressed an International Congress of Anesthesiologists, who had presented to him three questions regarding the use of resuscitation and respirators, technologies that were new at the time. The Pope’s response has been published under the title "The Prolongation of Life," and includes both a general philosophy and specific guidelines (Pius XII).
The general philosophy echoes themes I mentioned earlier: While "natural reason and Christian morals" require us to accept necessary treatment to preserve life and health, "normally one is held to use only ordinary means- -relative to circumstances. . .- -means that do not involve any grave burden for oneself or another." To require more "would render the attainment of the higher, more important good too difficult. Life, health, all temporal activities are in fact subordinated to spiritual ends" (Pius XII, pp. 395-96).
Specific points made by the Pope:
1) It is up to the medical and scientific professions to "give a clear and precise definition of ‘death’ and ‘the moment of death’ " and to provide criteria for diagnosing permanent unconsciousness (p. 396).
2) Resuscitation and respirators may be used, but only with consent of the patient or family (p. 397).
3) In "hopeless" cases, including cases of permanent unconsciousness, treatments such as resuscitation and respirators "go beyond the ordinary means to which one is bound," and thus there is no obligation "to give the doctor permission to use them" (p. 397).
4) Stopping artificial respiration "is never more than an indirect cause of the cessation of life, and one must apply in this case the principle of double effect" (p. 397).
The Aftermath
In this allocution Pope Pius XII showed that he supported the emerging consensus among Catholic theologians; and in fact, he seemed to place himself among the more flexible of these theologians. His speech was widely quoted and extended to a variety of other situations. See, for example, the insightful discussion by Richard McCormick, S.J., "To Save or Let Die," on the treatment of impaired and imperiled newborns. McCormick used the concept of "the higher good" to show that aggressive treatment of infants who could never have any "relational capacity" was not required.
The medical profession in the United States, however, became somewhat bewitched by its newfound technological abilities. CPR followed by intubation and long-term artificial respiration began to be regarded as "medically indicated." In addition, a climate of legal litigation led hospitals and their lawyers to advise doctors to protect themselves by preserving life whenever possible.
In the 1960s and 1970s, the medical profession tended to use the terms "ordinary" and "extraordinary" in a different way from the moral tradition. Ordinary means were defined by the medical profession as those that were available, in common use, or accepted medical practice, while extraordinary means were those that were unusual, experimental, or risky. Since respirators to prolong life were common by then, and it was accepted medical practice to use them if they were necessary for survival, therefore they had to be used. Moreover, physicians widely believed that a life-prolonging treatment could never be stopped once it had been started, that by doing so one would incur responsibility for killing the patient.
These two views- -the one coming out of the Catholic tradition, the other arising from medical practice- -were on a collision course. This conflict came to a head with case of Karen Ann Quinlan in 1975-76. The importance of this case cannot be overestimated.
Karen Ann Quinlan, age 21, passed out at a party, then stopped breathing. She was resuscitated and put on a respirator, still in a coma. Eventually she came out of the coma into the condition we now describe as permanent vegetative state. In this condition, the patient has sleep-wake cycles, opens her eyes, but is completely unresponsive and remains unconscious. (Brain studies done after Karen’s death confirmed this diagnosis.)
After months Karen’s family accepted her prognosis as hopeless and began to discuss what they should do. They were a devout Catholic family who relied on their Christian beliefs. In addition, they had lengthy discussions with their parish priest, whom Julia had worked for as parish secretary. Father Tom assured them that centuries of tradition, including the statements of Pope Pius XII, supported a decision to remove Karen’s respirator (Quinlan and Battelle).
Given the high level of public controversy about the case, Father Tom wanted a confirming statement from the local Catholic bishop. Though bishops rarely make statements about individual cases, Bishop Lawrence Casey of Paterson consented. Despite his weakness resulting from progressive cancer and two surgical operations, he left his hospital bed to make a public statement: Bishop Casey also stated that the Diocese of Paterson "firmly supports our beloved brother and sister in Christ, Joseph and Julia Quinlan, faithful members of the Parish of Our Lady of the Lake. . ." (p. 227).
Although Karen’s doctors at first seemed to agree, they soon backed down. The Quinlans eventually had to take their case to court. In court the treating physicians as well as expert medical witnesses all testified that "removal from the respirator would not conform to medical practices, standards and traditions" ("In the Case," p. 366), and that no ethical physician would do such a thing. The lower court heeded the expert medical testimony and refused Joseph Quinlan’s request to be appointed guardian and decision maker for his 21-year-old daughter. But the Quinlans, persuaded in conscience that they were right, appealed to the New Jersey Supreme Court.
Given the deference usually paid to expert medical opinion in such cases, it was somewhat astounding that the New Jersey Court took the side of the Quinlans. It argued that the medical profession did not have superior moral knowledge and the moral standards of a community and a family must also carry weight with the court. In this particular case, the moral standards were those of a Catholic community and a family whose values were formed by that tradition. The court’s decision allowed Mr. Quinlan to be named Karen’s guardian and permitted him to choose a doctor who would agree to follow the family’s wishes ("In the Case"). (Ironically, although the treating physicians had testified that Karen needed the respirator in order to breathe, she continued to live- -still unconscious- -for almost ten more years after the respirator was disconnected.)
Other Influences of Catholic Tradition
The Quinlan case deserves all the attention it receives as a landmark case. It integrated the basic principles of the Catholic moral tradition on refusal of life-sustaining treatment within the American legal system. Of course, many questions remained unsettled, particularly the issue of continuing artificial nutrition for a permanently unconscious person- -but the groundwork had been laid.
After the Quinlan case, the Vatican responded with a fine, well-reasoned document, "Declaration on Euthanasia," issued in 1980 ("Vatican Declaration"). While continuing to warn against the practice of euthanasia, the document carefully distinguished refusal of life-sustaining treatment from euthanasia. Possibly concerned about confusion in the use of the terms ordinary and extraordinary means, the document suggested a different language, the language of benefits and burdens, and of assessing proportionate and disproportionate means of treatment. This language was soon adopted in two sets of secular guidelines on life-sustaining treatment. The first was issued by a government body, the President’s Commission for the Study of Ethical Problems in Medicine, in 1983. Not only did the Commission utilize the same language as the Vatican, but in the appendix of its report it printed large portions of only two statements on medical ethics: that of the American Medical Association, and the Vatican "Declaration on Euthanasia" (President’s Commission, pp. 300-307). The second document that explicitly used the Vatican’s reasoning is the Guidelines on the Termination of Life-Sustaining Treatment from the influential Hastings Center (Hastings Center).
Pain Control
A somewhat different area of Catholic morality that has had far-reaching application is in the area of pain-control. In order to deal with situations where a proposed action has both a good and a bad effect, Catholic theologians at least as early as St. Thomas Aquinas (13th century) proposed a "double effect" principle. As developed precisely in later centuries, this principle gave conditions under which one could perform an action that had both good and bad effects: the action in itself had to be morally permissible; the good effect had to be what one intended, with the evil effect only an indirect consequence; and there had to be a good enough (proportionate) reason for allowing the bad effect to occur (Connell; Mangan).
While this principle has been applied to a variety of situations, from bombing that kills civilians in wartime, to abortion that removes a threat to the mother, it is the application to the control of pain that is of interest to us here. The Catholic tradition argues that medication to control pain may be given to a suffering person in dosages that are adequate even if increasing dosages may depress the patient’s respiration and hasten the time of death. One intends to relieve pain, and does what is necessary for that purpose. A hastened death is the indirect and not the intended effect.
While the double effect principle is still debated among Catholic theologians as to its coherence and adequacy, it seems to have filled a practical need of medical professionals, lawyers, and bioethicists searching for philosophic grounding for an intuitively acceptable practice. Patients should receive adequate pain relief, and shouldn’t be forced to suffer needlessly. A professional who responsibly provides such pain relief shouldn’t fear being accused of causing death or committing homicide. Two cases in which the medical examiner in Hennepin County brought such charges against physicians led to a position paper issued by the Hennepin County Medical Society that is essentially a statement of the Catholic principle of double effect (Hennepin County). In the wake of these events, most local hospitals have developed similar policies that encourage adequate pain control and invoke double-effect reasoning to ground the ethical prescription of adequate pain control measures.
A Turning Point
The subtitle of this lecture is, "Behind the Assisted Suicide Debate." While we have achieved a broad consensus on life-sustaining treatment, on patient and family oriented decision making, and on pain relief, we are also witnessing a new movement that breaks through the careful distinctions built up over centuries.
Jack Kevorkian regularly assists both terminally and chronically ill persons to end their lives, at their own request. Though Kevorkian has been prosecuted three times for conduct regarded as illegal under Michigan and common law, no jury seems to want to convict him. In one of his trials he turned around the statement of the double effect principle in Michigan law to his own advantage. The law states that a physician is not responsible for causing the death of the patient if the physician’s intention in providing medication is to relieve pain. Kevorkian’s lawyer argued that Kevorkian set up the mechanism for providing carbon monoxide to suffering persons because he intended to relieve their suffering, not in order to cause their death. Since the jury apparently accepted this argument, one might ask whether the double effect principle is able to do all the work we expect of it.
A more serious breach in the traditional distinctions occurred on March 6, 1996 and again on April 2, 1996. On these dates, two U.S. Circuit Courts of Appeals (one ruling on a Washington state law, one on a New York law) struck down state laws against assisted suicide as being unconstitutional. While juries do not have to give rational explanations for their decisions, the two appeals courts did have to. Both of them stated that, in the context of terminal illness, there is essentially no difference between ending medical treatment that artificially prolongs life, and taking active steps to bring about or hasten the moment of death. The Washington court, for example, said: The statement that there is no ethical difference ignores a history of careful differentiation, both theoretical and practical. Dr. Ronald Cranford, neurologist at Hennepin County Medical Center, expresses a consensus view: Cranford calls for hospital ethics committees to be proactive in continuing to point out these distinctions.
Many people believe it is too soon for the U.S. Supreme Court to take on this issue and settle it. We haven’t had enough public discussion and we certainly lack agreement. But the Supreme Court has decided to take the case, will hear arguments in January 1997 and will announce its decision by July.
Summary
The Catholic intellectual tradition has played a significant and influential role in developing a public and secular bioethics about life-sustaining treatment and the care of the dying. The principles of this tradition seem to have an intuitive appeal for persons who are searching for compassionate and patient-centered ways of caring for the dying and easing their ordeal. How will these principles stand up to the legal challenges that are now questioning their coherence and even their ethicality? Is there enough wisdom in them to meet these challenges- -or will we have to engage in a radical reevaluation?
References

Connell, F.J. "Double Effect, Principle of." New Catholic Encyclopedia (1967): 1020-1022.

Cranford, Ronald. "25 Years of Ethics Committees." Newsletter: Center for Biomedical Ethics, University of Minnesota Fall 1996: 1.

Greenhouse, Linda. "High Court to Say if the Dying Have a Right to Suicide Help." New York Times 2 Oct. 1996, nat. ed.: A1 and A12.

Hastings Center. Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying. Bloomington: Indiana University Press, 1987.

Hennepin County Medical Society. "Position Paper on Management of Pain and Suffering in the Dying Patient." Minnesota Medicine 73.6 (June 1990): 36-37.

Kelly, Gerald, S.J. "The Duty of Using Artificial Means of Preserving Life." Theological Studies 11 (1950): 203-220.

Kelly, Gerald, S.J. "The Duty to Preserve Life." Theological Studies 11 (1951): 550-556.

Mangan, Joseph T. "An Historical Analysis of the Principle of Double Effect." Theological Studies 10 (1949): 41-61.

McCartney, James J., O.S.A. "The Development of the Doctrine of Ordinary and Extraordinary Means of Preserving Life in Catholic Moral Theology." Linacre Quarterly (Aug. 1980): 215-224.

McCormick, Richard A., S.J. "To Save or Let Die." Journal of the American Medical Association (JAMA) 229 (1974): 172-176.

New Jersey Supreme Court. "In the Matter of Karen Quilan. An Alleged Incompetent." Contemporary Issues in Bioethics. Ed. Tom L. Beauchamp and LeRoy Walters. 2nd ed. Belmont, CA: Wadsworth, 1982. 365-372.

Pius XII, Pope. "The Prolongation of Life." The Pope Speaks 4 (1958): 393-398.

President’s Commission for the Study of Ethical Problems in Medicine. Deciding to Forgo Life-Sustaining Treatment. Washington, D.C.: U.S. Government Printing Office, 1983.

Quinlan, Joseph and Julia with Phyllis Battelle. Karen Ann: The Quinlans Tell Their Story. Garden City, NY: Doubleday & Company, 1977.

Soloman, Andrew. "A Death of One’s Own." New Yorker 71.13 (22 May 1995): 54-69.

"Vatican Declaration on Euthanasia." Origins 10 (1980): 154-157.
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