This article appears in the May 2011 Edition of the Catholic Medical Quarterly
MUST LIFE ALWAYS BE PROLONGED?
University of Illinois - College of Medicine
This is an open ended question and for that reason, difficult to answer. We agree that life is a natural good and should not be wilfully terminated (self-defence and a just war being exceptions). But we can, in many (if not moist) instances, prolong life (respiration and a beating heart) almost indefinitely. Examples of methods to accomplish this, to name a few, are parental entrostomal gastrostomy (PEG), renal dialysis and cardiac extenders (defibrillators and left ventricular assist devices (LVAD).)' With more of these life prolonging options being utilized, the opening question, "Must life be prolonged?" becomes ethically critical.
Obviously the answer is "yes" and "no". The Church's position is that each individual patient (not the doctor or ethicist) must decide for him or herself (Ethical and Religious Doctrine (ERD) 57 and 59).2 We will briefly review several relevant issues, using as an example artificial hydration and nutrition (AHN) for those unable or unwilling to take food and water. These issues are
- The Catholic theology of death,
- The variety of circumstances regarding AHN,
- The conclusion.
THEOLOGY OF DEATH
Death, physiologically, is the irreversible cessation of respiration and circulation. Vital cellular functions cease and necrosis begins.
Philosophically, life begins at conception when the genetic matter of the sperm and egg fuse and the vital form of a human soul infuses that matter. Death, on the other hand, is the dissolution of this matter and form. But, as the philosopher (3) says, the soul is immaterial and therefore eternal. Theologically, at conception God creates the human person. A person, during the formative years, attains the knowledge of right and wrong and realizes that his/her eternity will be judged by one's earthly behaviour. The existence of the afterlife, and eternal reward and punishment, are attested to by not only the great religions but also by an examination of the major civilizations. (4). The fact that some in our modern culture dispute these facts in no way disproves them.
Death for the Christian, has been transformed from a curse into a blessing. In death, God calls man to himself. The Catechism states that, "The Christian can experience a desire for death like St. Paul's, 'My desire is to depart and be with Christ"' (5&6)
In the Catholic tradition death is a neutral event, neither good nor bad. But for most humans death is generally seen in a negative light. It is often associated with aging and the associated suffering and disabilities. Death is usually preceded by serious progressive diseases such as diabetes or cancer that are associated with pain and incapacitation. While death is often times a release from suffering it is identified with the anguish often associated with the last days of life. The dying process is feared and humans want to be in control of it.
Using AHN as an example we will briefly discuss the ethical issue of whether life must be prolonged by a PEG. In general, if a patient is not dying, AHN is mandated as usual and customary nursing care. This applies to the persistent vegetative state. But AHN s not always mandated in terminal conditions. What a terminal condition is has been debated. Certainly end stage cancer is terminal. Patients with a metastatic advanced malignancy can legitimately refuse AHN and stop eating if that patient feels that this form of treatment is burdensome for them. Frailty is a more debatable syndrome.
A corollary of aging is frailty which is often accompanied by a loss of appetite. Some feel that frailty is part of the dying process. Loss of appetite sometimes can be alleviated by enhancing bland food. As humans age their metabolism slows and fewer calories are required to maintain life. A diminished appetite, in this setting, can be considered normal. This in turn can lead to further wasting and increased frailty.
Does the Catholic Church morally require that such a patient consent to a PEG placement? The ERD's suggest that burdensome treatment is not required and that this determination should be made by the patient. Others feel that a PEG is required. There is an ample literature which suggests that PEG assisted AHN not only does not necessarily prolong life, but may even have a significant morbidity and morality of its own. (7)
Some argue that any hastening of death, as some hospices are accused of doing by discontinuing certain medications and life
support systems in terminal situations, is unethical. Using this argument, no "do not resuscitate" (DNR) order would be moral because many arrested hearts can be restarted. These resuscitative efforts are often times grim ordeals that most families should not witness, and are usually unsuccessful. Is a consent to a DNR order an indirect suicide because, by it, the patient is certain to die when he/she might have been revived? (9)
Returning to the original questions, "Must life be artificially prolonged?" we conclude that it can, but need not be. Death, viewed from a Catholic perspective, can be welcomed. As mentioned, St. Paul, "desired death". Extraordinary means, certainly to include PEG's, dialysis, and LVAD's, are not mandated in all instances. The individual patient decides what is burdensome for his/her self.
Professor Patrick Guinan was formerly Chairman of the Division of Urology of both Cook County Hospital and the University of Illinois College of Medicine. He is presently President of the Catholic Physicians Guild of Chicago and Chairman of the Board of the Hektoan Institute of Medical Research
- Fang, James. The Rise of Machines: Left Ventricular Assist Device on Permanent Therapy for Advanced Heart Failure.
- United States Conference of Catholic Bishops. Ethical and Religious Directives for Catholic Health Care Services. Washington, D.C. 1995 /p>
- Aristotle; On the Soul Book, Great Books. Encyclopedia Brittanica. 1952, page 631
- Toynbee, Arnold. A Study of History. Weathervane Books, New York. 1972 Ch 10, page 85
- Philippians 1:23
- Catechism of the Catholic Church # 1011, p 263. Libreria Editrice Vaticana, Urbi et Orbis. New Hope, Ky. 1994
- Li, Ina. "Feeding Tubes in Patients With Severee Dementia", American Family Physician V:65 (April 15, 2002)