The Hour Of Our Death

The final installment in the Register’s look at culture-of-death influences in end-of-life care.

end of life series, part 3

In earlier parts of this three-part series on end-of-life issues, we discussed how some hospices are redefining extraordinary treatment, showing less concern for the sanctity of life than for a quality of life, and how right-to-life organizations are concerned about eroding values in the care of the terminally ill. In this final part of the series, we hear from experts in the teachings of the Catholic Church on these issues.

Legally, the battle for “dying in God’s time,” in the words of anti-euthanasia activist and North Carolina resident Betty Wickham, may already have been lost.

In 1975, the Catholic parents of Karen Anne Quinlan were allowed by the New Jersey Supreme Court to disconnect their comatose daughter from her respirator, but her parents would not remove her feeding tube; she lived for another nine years.

The court quoted Pope Pius XII, who said that ending extraordinary medical treatment such as a mechanical breathing machine did not constitute euthanasia in a case like hers.

But in 1990, the U.S. Supreme Court did not refer to Church teaching in the case of Nancy Beth Cruzan, when it ruled that Cruzan’s parents could remove her feeding tube. She died 11 days later, probably from a combination of starvation and dehydration.

A North Carolina bill that was signed into law in August allows for “back door euthanasia,” according to the vice president of the state chapter of the Catholic Medical Association, Dr. Kenneth McElynn.

“All coma patients across the board are placed in serious jeopardy,” said McElynn. “The bill creates a dangerous new advance directive form called a ‘Medical Order for Scope of Treatment,’ also known as the MOST form. The form originates from Oregon’s right-to-die movement and its promotion is part of their national campaign.”

The problem that pro-life medical professionals such as McElynn see with new directives and with the changing terminology being used in palliative care these days is that caregivers and the terminally ill are beginning to accept what used to be unacceptable — and what the Church still finds unacceptable. And even when they don’t, euthanasia appears to be on the fast track to becoming the new de facto law of the land.

John Luce and Ann Alpers, writing in the American Journal of Respiratory and Critical Care Medicine, said so-called terminal sedation, where a patient is rendered comatose by medication and then, since the patient is never expected to regain consciousness, may have food and water withdrawn, is fast becoming legally acceptable. The same might be said of outright mercy killing, in fact if not always in statute.

“Overall, cases of suspected assisted suicide or euthanasia are difficult to prosecute successfully. … If the patient and family consented to palliative care,” Luce and Alpers wrote.

Food and Water

John Brehany, an ethicist and executive director of the Catholic Medical Association, noted that a debate has been going on for years about the moral acceptability of withholding food and water from a terminal patient. He said the association supports Pope John Paul II’s March 20, 2004, statement to the International Congress on “Life-Sustaining Treatments and the Vegetative State.”

“The sick person in a vegetative state, awaiting recovery or a natural end, still has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.) and to the prevention of complications related to his confinement to bed,” the Pope said on that occasion. “I should like to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and, as such, morally obligatory.”

“In principle, nutrition and hydration are considered ordinary and proportionate means of care. If you can feed them, you should,” Brehany said. “There are occasions when feeding someone may rise to the level of extraordinary [care]; then, you can withhold it.”

Those exceptions, Brehany said, might be when a dying person cannot assimilate food and/or water, or when one or the other causes serious discomfort.

Father Tadeusz Pacholczyk, director of education for the National Catholic Bioethics Center, agreed with Brehany and added as an exception a situation where a feeding tube fails to provide actual nourishment, as in the case of advanced cancer of the digestive tract.

“As a general rule,” Father Pacholczyk said, “we should die from a disease or ailment that claims our life, not from an action by someone that causes our death. … There should be a presumption in favor of providing nutrition and hydration to all patients, including those who require the assistance of a feeding tube.”

Terminal Sedation

According to the principle of double effect, we can relieve someone’s pain — if that is our intent — while still rendering him comatose or shortening his life as a secondary effect. But that necessary intent is missing when palliative care professionals induce what is known as terminal sedation.

“They have something else in mind,” Brehany said. “Their purpose is to end any consciousness and then withdraw nutrition and hydration. The boundaries have been slipping, and food and water have been defined by some as extraordinary medical treatment.”

Many hospitals recommend that people fill out a living will, a form of advance directive, telling medical personnel how to treat the patient as far as extraordinary care goes if he becomes seriously ill. The trouble with living wills is that they cannot anticipate every possible scenario. Father Pacholczyk calls them “blunt instruments.”

“There is a better choice available to Christians than a living will,” he said. “We can choose a surrogate, a living person, who will make health care decisions in real time on our behalf if we are rendered unable to do so. The surrogate is someone who cares deeply about us, who loves us, and is reasonably able to make decisions in accord with our known wishes and with our best medical and spiritual interests in mind.”

Brehany said that Catholics can be easy in mind about end-of-life decisions, because their Church has the moral authority and the expertise to work out all the complicated value judgments ahead of time.

“The teachings of the Church are very reasonable,” he said, and we just have to get out there and witness to them in a charitable manner.”

Paul A. Barra writes from

Reidville, South Carolina.