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Prolife Forum: Refusal of medical treatment

by Catherine Frakas 13 Jun 2002

Refusal of medical treatment QUESTION from Marian G.M. Van den Meydenberg August 15, 2001 For some time now I have been thinking of a question that was asked me. Is the stopping or refusal of medical treatment for (terminal) diseases a form of suicide.
For instance, I intend to never accept a feeding tube to prolong my life after a cerebral vascular accident (CVA), stroke. Is this considered suicide? Is it my duty to accept medical treatments to prolong life?
Is even the taking of medications for diseases such as diabetes or heart disease must? What if one refuses those, knowing that death certainly will come earlier.
I am awaiting your answer....
Gratefully, Marian

ANSWER by Mr. Troy Martz on August 2, 2001 Dear Mrs. Van den Meydenberg:
Thank you for your question, I know that these are often difficult questions when it comes to trying to live God's will in our lives. This is one of the most beautiful gifts God gives us in the Church: moral, God-centered leadership. The universal Church, through the Pope in union with the Bishops of the world, give us principles as expression of the faith which we must obey; our bishops and pastors help (or are supposed to) us apply these principles to individual situations. Here is an example of such pastorial guidance.
The following is taken from the US Conference of Catholic Bishops' Pro-Life Activities Directorate:

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.
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. 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. 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.
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.
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. 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. 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.
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.
What are the benefits of medically assisted nutrition and hydration?
According to international codes of medical ethics, a physician will see a medical procedure as appropriate if in his or her judgment it offers hope of saving life, reestablishing health or alleviating suffering.
Nutrition and hydration, whether provided in the usual way or with medical assistance, do not by themselves remedy pathological conditions, except those caused by dietary deficiencies. But patients benefit from them in several ways. First, for all patients who can assimilate them, suitable food and fluids sustain life, and providing them normally expresses loving concern and solidarity with the helpless. Second, for patients being treated with the hope of a cure, appropriate food and fluids are an important element of sound health care. Third, even for patients who are imminently dying and incurable, food and fluids can prevent the suffering that may arise from dehydration, hunger and thirst.
The benefit of sustaining and fostering life is fundamental, because life is our first gift from a loving God and the condition for receiving His other gifts. But sometimes even food and fluids are no longer effective in providing this benefit, because a patient has entered the final stage of a terminal condition. At such times we should make the dying person as comfortable as possible and provide nursing care and proper hygiene as well as companionship and appropriate spiritual aid. Such a person may lose all desire for food and drink and even be unable to ingest them. Initiating medically assisted feeding or intravenous fluids in this case may increase the patient's discomfort while providing no real benefit; ice chips or sips of water may instead be appropriate to provide comfort and counteract the adverse effects of dehydration. Even in the case of the imminently dying patient, of course, any action or omission that of itself or by intention causes death is to be absolutely rejected.
As Christians who trust in the promise of eternal life, we recognize that death does not have the final word. Accordingly we need not always prevent death until the last possible moment; but we should never intentionally cause death or abandon the dying person as though he or she were unworthy of care and respect.
What are the burdens of medically assisted nutrition and hydration?
Our tradition does not demand heroic measures in fulfilling the obligation to sustain life. A person may legitimately refuse even procedures that effectively prolong life, if he or she believes they would impose excessively grave burdens on himself or herself, or on his or her family and community. Catholic theologians have traditionally viewed medical treatment as excessively burdensome if it is too painful, too damaging to the patient's bodily self and functioning, too psychologically repugnant to the patient, too restrictive of the patient's liberty and preferred activities, too suppressive of the patient's mental life, or too expensive.
Because assessment of these burdens necessarily involves some subjective judgments, a conscious and competent patient is generally the best judge of whether a particular burden or risk is too grave to be tolerated in his or her own case. But because of the serious consequences of withdrawing all nutrition and hydration, patients and those helping them make decisions should assess such burdens or risks with special care.
Here we offer some brief reflections and cautions regarding the kinds of burdens sometimes associated with medically assisted nutrition and hydration.
[More deletions . . .]
First, in keeping with our moral teaching against the intentional causing of death by omission, one should distinguish between repugnance to a particular procedure and repugnance to life itself. The latter may occur when a patient views a life of helplessness and dependency on others as itself a heavy burden, leading him or her to wish or even to pray for death. Especially in our achievement-oriented society, the burden of living in such a condition may seem to outweigh any possible benefit of medical treatment and even lead a person to despair. But we should not assume that the burdens in such a case always outweigh the benefits; for the sufferer, given good counseling and spiritual support, may be brought again to appreciate the precious gift of life.
Second, our tradition recognizes that when treatment decisions are made, account will have to be taken of the reasonable wishes of the patient and the patient's family, as also of the advice of the doctors who are specially competent in the matter. The word reasonable is important here. Good health care providers will try to help patients assess psychological burdens with full information and without undue fear of unfamiliar procedures. A well-trained and compassionate hospital chaplain can provide valuable personal and spiritual support to patients and families facing these difficult situations.
Third, we should not assume that a feeding procedure is inherently repugnant to all patients without specific evidence. In contrast to Americans' general distaste for the idea of being supported by tubes and machines, some studies indicate surprisingly favorable views of medically assisted nutrition and hydration among patients and families with actual experience of such procedures.
[I have deleted portions due to space constraints]
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.
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. 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. 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.
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:

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.
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.
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.
[More deleted] See the complete document, Nutrition and Hydration: Moral and Pastoral Considerations (1992) for a fuller discussion of these and related issues.
As you can see above, authentic Catholic teaching is balanced (neither save life at any costs, nor euthanize those who become the slightest burden) and always preserves the dignity of a human person made in the image and likeness of the Eternal God.
Pax Christi,Troy Martz

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