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The recent case involving Alfie Evans—a toddler in England suffering from a serious neurological condition, whose doctors discontinued his life support amid legal and media battles over his rights and care, leading to his death—has re-raised common questions many people have about Church teaching in this area.
For example: At what point should medical treatment be removed from a patient? Do patients have to be kept alive by machines?
It would be a misrepresentation of Catholic teaching and good medical practice to say that we are morally obliged to “overtreat” patients—using every means available to sustain or prolong life. In many circumstances, life-sustaining medical treatment may indeed be discontinued, according to a prudential ethical analysis.
The US bishops have written about this in their Ethical and Religious Directives guide to Catholic hospitals and health care providers. These ERDs are helpful and instructive for people looking for a solid set of ethical end-of-life principles.
Paragraph 56 states, “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.” The following paragraph provides a contrast to this: “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.”
So we see that, far from insisting that everything possible be done to sustain a life, the Church’s guidance shows us how to prudently weigh whether the benefit of a proposed treatment outweighs the burden it would impose.
Now, some people do take the position that there is a moral obligation to use any and all possible means to preserve and sustain life. This “vitalistic” perspective is permissible; someone would be within his rights to demand it for himself and indicate as much in his advance directives. But neither Catholic teaching nor traditional medical ethics makes this standard obligatory, and most people do not request it for themselves.
When considering a medical procedure or treatment in a particular circumstance, it’s appropriate to weigh the expected benefit of the procedure or treatment against the burden it will impose on the patient. (Note that we are considering the burden of the treatment, not the putative burden of the patient’s life.) If the burden is deemed to outweigh the benefit, then the treatment can morally be foregone.
For example, if a proposed treatment is very expensive and has debilitating side effects, and the best that can reasonably be hoped for is that it will extend the patient’s life by a few months (a chemotherapy protocol when the patient has advanced-stage cancer might fit this description), a person could choose not to pursue it.
And so a person may, in certain circumstances, refuse medical treatment for himself or make that decision for another as his advocate or guardian. We are not required to pursue every possible medical option available as if its burdens had no bearing on the decision. It’s really a balancing test.
A similar test applies when determining whether to cease medical treatment for someone who is already dependent on it to live. Ordinarily, such treatment should be continued. But there are circumstances that might call for stopping it, circumstances to be evaluated according to the same kind of burden/benefit analysis used to determine whether to begin such treatment.
How much is the procedure/treatment going to help? What burdens will it place upon the patient? This calculation must also include the fact that the patient is already undergoing the treatment and is dependent upon it for continued life.
When calculating the benefits of treatment, caution must be exercised to prevent falling into a “futile care” mentality that rejects any treatment that doesn’t restore someone to robust health. This is not the appropriate standard by which to weigh a treatment’s expected benefit, especially when the decision is being made by an insurance company or a government bureaucrat whose incentive is to save money. Even the restoration to moderate health, for a very ill patient, should be recognized as a great benefit.
The state of medical technology must also be factored into the proportionality assessment. Treatment that might have been deemed “extraordinary” in the past might be quite routine today. For example, simple surgical procedures such as an appendectomy or kidney dialysis were once seen as extraordinary treatment options but today are commonplace.
A common followup question is: What about a feeding tube? Is there a different standard for deciding to withdraw that treatment?
Yes. The standard for removing a feeding tube generally is different—though it is common for people to conflate food and water provided intravenously or through a tube with “life-sustaining medical treatment.” In fact, just as the question implies, most hospitals consider “tube feeding” as “medical treatment.” However, food and water—no matter how they are administered—are not medical treatment but ordinary, basic care, and should be provided in all cases unless or until the body can no longer process them.
We need to think about what is actually being provided. Is it medicine, which cures a problem or provides therapeutic benefit? Or is it basic food and water, which every living thing—not just those who are ill—needs? The method of transmission is not essential; the aspirin you swallow to cure a headache is no more “food” than a can of liquid nutrition supplement is “medicine,” whether it is taken orally or by a tube inserted in the stomach.
All human beings need four things to stay alive: warmth, hygiene, food, and water. Without any of these, everyone will die, whether an Olympic athlete or an 87-year old with Alzheimer’s. Remove someone’s warmth by leaving him outside in the Arctic Circle in January without a coat or a source of heat, and he will die quickly. Stay in the same position on the couch watching television for four weeks without moving (or being moved), and your pressure sores will fester and become infected and you will die. Prevent anyone from eating and he will die within a few weeks. Prevent him from drinking and he will die within a week.
To point out that food and fluids are essential, ordinary care is not to say that they should never be removed. When death is truly imminent, the body begins to shut down. A person in that state will usually stop eating and drinking of his own volition. He simply isn’t hungry or thirsty anymore. It serves nothing to force people to eat when their bodies are no longer assimilating the nutrition. In fact, it can actually make them more uncomfortable. With this reality in mind, it is reasonable and ethical for the patient’s decision-maker to discontinue food and water on behalf of a dying patient when the patient is unable to communicate his own wishes. When the patient dies soon after, it is from his terminal medical condition, not from dehydration or starvation.
But it is, unfortunately, not an uncommon practice for patients in hospitals to die of dehydration. The horror of it is usually masked by morphine or other sedatives, but it is an awful way to die. In no case is it ethically permissible as a means of “mercifully” ending a patient’s life.[1]
It also bears mentioning that tube feeding is neither new nor expensive—in fact, it has been in successful use for more than a hundred years. So in most of the civilized world there’s nothing burdensome or extraordinary about the use of a feeding tube. It is basic care to which every human being’s innate dignity grants him the right.
[1] There is the rare case of a particular condition that makes the digestion of food and water excruciating, such as some types of advanced stomach cancer. In such cases, where the patient may not actually be in the dying process but cannot handle digestion, most ethicists agree that it is acceptable to withhold food and water, even if the patient dies thereby, provided the patient is aware of this and gives consent. As they say, though, “Hard cases make bad law,” so this rare exception does not alter the general principle that sick people are not to be denied food and water.
For more about Church teaching in these difficult medical cases, check out Jason’s booklet, 20 Answers: End of Life Issues, available from Catholic Answers Press.