End of Life Decisions: Ordinary versus Extraordinary Means

Author: Colin B. Donovan, STL

The court-ordered starvation and dehydration of Terri Schiavo in 2005 raised a number of issues—moral, legal and constitutional, about the right to life and the so-called right to die. Most coverage of the case focused on the question of her guardian's right to decide according to her alleged wishes and the due process of the judicial proceedings. However, at base the question was a moral, not a legal, one: under what conditions, if any, may a patient, a guardian, medical personnel or civil authorities, withhold or withdraw nutrition and hydration?

Catholic Teaching on Ordinary & Extraordinary Means

The natural law and the Fifth Commandment* requires that all ordinary means be used to preserve life, such as food, water, exercise, and medical care. Since the middle ages, however, Catholic theologians have recognized that human beings are not morally obligated to undergo every possible medical treatment to save their lives, even very ordinary ones.

Treatments that are 1) unduly burdensome or 2) sorrowful to a particular patient, such as amputation, or 3) beyond the economic means of the person, or 4) which only prolong the suffering of a dying person, become morally extraordinary for that person, even if they are otherwise medically ordinary or common. They may choose to use them, but they are not morally obliged to do so.

The many advances in medicine during recent decades have greatly complicated the decision whether to undergo or forego medical treatment, since medicine can now save many people who would simply have been allowed to die in the past. Further, having saved them, many people continue to live for long periods in comatose or semi-conscious states, unable to live without technological assistance of one kind or another. This means that great care is required in applying the moral law to particular cases, and each person should consider how they will do so, and how they will ensure that they receive morally appropriate care when they are not able to decide for themselves.  

*The 5th Commandment (Dt. 5:17), 6th in Protestant usage (Ex 20:13), says "Thou shalt not kill." The implicit corollary is that one must save life, one's own and others by reasonable care (not driving too fast, not taking drugs, seeing a doctor if home care cannot effect a cure of sickness, etc.).  (cf. Catechism of the Catholic Church 2268-2269).

End of Life Q&A

Q. When may medical therapies, procedures, equipment and the like be withheld or withdrawn from a patient.

A. The Catechism of the Catholic Church states,

2278. Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of "over-zealous" treatment. Here one does not will to cause death; one's inability to impede it is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected.

The key principle in this statement is that one does not will to cause death. When a person has an underlying terminal disease, or their heart, or some other organ, cannot work without mechanical assistance, or a therapy being proposed is dangerous, or has little chance of success, then not using that machine or that therapy results in the person dying from the disease or organ failure they already have. The omission allows nature to takes its course. It does not directly kill the person, even though it may contribute to the person dying earlier than if aggressive treatment had been done.

Q. Does this also apply to artificially provided nutrition and hydration?

A. Yes, when the moral conditions noted above are met. We must, therefore, ask the question "will the withdrawal of nutrition and hydration allow the person to die, or kill the person?" When it will allow a person to die from an underlying condition, rather than unnecessarily prolonging their suffering, it may be removed. So, for example, in the last hours, even days, of a cancer patient's life, or if a sick person's body is no longer able to process food and water, there is no moral obligation to provide nutrition and hydration. The patient will die of their disease or their organ failure before starvation or dehydration could kill them. However, when the withdrawal of nutrition and hydration is intended to kill the person, or will be the immediate and direct cause of doing soquite apart from any disease or failure of their bodies, then to withdraw food and water would be an act of euthanasia, a grave sin against the natural law and the law of God.

Q. What does the Church say about this?

A. Pope St. John Paul II addressed this issue in an address to a group of physicians who were in Rome in March 2004 precisely to discuss it.

I should like particularly 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, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering.

The obligation to provide the "normal care due to the sick in such cases" (1) includes, in fact, the use of nutrition and hydration. (2)  The evaluation of probabilities, founded on waning hopes for recovery when the vegetative state is prolonged beyond a year, cannot ethically justify the cessation or interruption of minimal care for the patient, including nutrition and hydration. Death by starvation or dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission.

In this regard, I recall what I wrote in the Encyclical Evangelium Vitae making it clear that "by euthanasia in the true and proper sense must be understood an action or omission which by its very nature and intention brings about death, with the purpose of eliminating all pain"; such an act is always "a serious violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person" (n. 65). [To the Congress on Life-Sustaining Treatments and Vegetative State, 20 March 2004)

(1) Congregation for the Doctrine of the Faith, Iura et Bona, p. IV

(2) cf. Pontifical Council "Cor Unum", Dans le Cadre, 2, 4, 4; Pontifical Council for Pastoral Assistance to Health Care Workers,Charter of Health Care Workers, n. 120

In this address the Holy Father draws the following significant conclusions:

1. Food and water are natural means of sustaining life, not medical acts, even if delivered artificially. 
2. Nutrition and hydration are ordinary and proportionate means of care. 
3. Food and water are morally obligatory unless or until they cannot achieve their finality, which is providing nutrition and hydrating and alleviating suffering. 
4. The length of time they are, or will be, used is not grounds for withholding or withdrawing artificially delivered nutrition and hydration. 
5. If the result of withholding or withdrawing nutrition and hydration is death by starvation and dehydration, as opposed to an undying disease or dysfunction, it is gravely immorally.

In summary, nutrition and hydration, like bathing and changing the patient's position to avoid bedsores, is ordinary care that is owed to the patient. This is true even if it is delivered artificially, as when a baby is bottle-fed or a sick person is tube-fed.

Nutrition and hydration may only be discontinued when they cannot achieve their natural purposes, such as when the body can no longer process them, or, when during the death process they would only prolong the person's suffering. In such a case the patient dies of the underlying disease.

On the other hand, if starvation and dehydration is the foreseeable cause of death, to withhold or withdrawn nutrition and hydration is gravely immoral.

In all cases, it is necessary for the individual, or their proxy, to obtain trustworthy medical advice on the medical circumstances, and trustworthy spiritual and moral advice regarding the decision to withdraw or withhold medical care at the end of life. It should also be stated in the Advance Directive that all parties follow Catholic moral teaching in this regard and in all aspects of one's medical care.

Q. What about the case of Terri Schiavo?
A. In Terri's case, while there was some disagreement as to her exact medical condition, but she was not dying. Indeed, when the other artificial means were withdrawn she continued to live, so that the withdrawal of her food and water directly caused her death. This was a violation of the natural law and the law of God.

Q. You mention the natural law, what is it?
A. The natural law is morality which reason can determine from the nature of man, without the assistance of God's revelation. An example is the right to life. Almost all human societies throughout history, both religious and non-religious, have recognized that it is wrong to kill an innocent person. This is a conclusion which reason can easily come to, since all human beings have an inborn desire to live. From this natural law principle we can easily see that any action that directly and intentionally kills an innocent person is an unjust taking of a human life. Therefore, withdrawing food and water from anyone who is not about to die and who can still tolerate it, has no other reasonable name than murder.

Q.  What do I ensure that my wishes and beliefs are respected by my family, medical personnel and the courts?
A. The best way is by means of an Advance Directive which states the patients wishes with respect to aggressive medical treatment. There are two basic kinds, 1) a Living Will by itself or 2) an Advance Directive together with a Durable Power of Attorney for Health Care Decisions (or Health Care Proxy). The merits of each are as follows:

1. Living Will by itself

By this document a person decides completely in advance whether they want to be kept alive by technology. It is a "yes" or "no" statement, which then places the matter in the hands of the medical community. Many Catholic bishops and moralists consider this an unsatisfactory approach, as it does not provide for unforeseen circumstances. Despite the enthusiasm of the media, many medical professionals, and sadly even some Catholic institutions, Living Wills are NOT the way to go!

2. Advance Directive AND Durable Power of Attorney for Health Care Decisions (or Health Care Proxy).

The first of these two documents, the Advance Directive, states one’s general will regarding aggressive medical care. To that extent it is like a Living Will. However, it should also include other important provisions, such as the will to adhere to Catholic teaching on end-of-life decisions, especially in the matter of withdrawing nutrition and hydration. It should address matters of spiritual care, including to be visited by a priest, to receive the sacraments of the Church, and, should it become necessary, to receive a funeral and burial in keeping with Catholic teaching and discipline. By making one's intentions known in the Advance Directive, one seeks to ensure that no one will disregard them when you are unable to make decisions for yourself.

Since general provisions for the end-of-life cannot foresee all circumstances, the Durable Power of Attorney for Health Care Decisions, or Health Care Proxy, is also necessary. Even when the Directive is clear in its preferences, there can be marginal or unforeseen cases where your instructions are not clearly applicable, or simply different than you envisioned. The Durable Power of Attorney legally empowers your Proxy to make those decision on your behalf, in accorance with your mind and will, as best as it is known.

For more information:

The National Catholic Bioethics Center has an End-of-Life Guide available on their website for printing. While state laws on the format, obligatory content and witnessing required, varies, the Center also has an information package that includes examples of an Advance Directive and a Health Care Proxy/Power of Attorney.

NCBC End of Life Guide 


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