A review of the Catholic Church's teaching on end of life decisions from a Catholic medical ethics standpoint, with an emphasis on the teachings of Pope John Paul II.

1. A Catholic Approach
to
End of Life Decisions
Jeffrey E. Mathews, MD, APC
Our Lady of Providence Parish
October 27, 2010

2. A Lifetime of Health Care
Health Care is a part of all of our lives, from the very
beginning to the very end of our lives, including all
the good and the bad in between.
We seek Health Care to prevent illness and treat any
diseases or injuries that we encounter during our life
on Earth.

3. Why do people choose to work in
the Medical field?
 It is love for the
suffering individual
that has drawn
Catholics into health
care and restrains
them from ever doing
anything that would
harm or violate that
individual in any way.

4. Good Medicine vs. Bad Medicine
 Medicine is the knowledge of
how to maintain health, not
knowledge of what is the good
 In learning what doses of
medications can help or harm
a patient, we must know what
will kill a person.
 Just because physicians and
other health care
professionals have the
knowledge of what could kill a
patient does not mean he or
she should use it for this
purpose.

5. The History of Catholic Medical
Ethics
 In 1595, at the end of the High Renaissance,
the Dominican theologian Domingo Banez
made a distinction that has become classic in
medical ethics: the distinction between
ordinary and extraordinary means.
 His writings first clearly state that ordinary
means of preserving life and conserving
health are morally obligatory because of the
responsible stewardship humans are charged
with by God.
 He continues:

6. Domingo Banez
 “Although a man is held to conserve his own
life, he is not bound to extraordinary means
but to common food and clothing, to common
medicines, to a certain common and ordinary
pain: not, however, to a certain extraordinary
and horrible pain, nor to expenses which are
extraordinary in proportion to the status of
this man... Although that means [amputation]
is proportioned according to right reason and
from the consequence is licit, it is, however,
extaordinary.”

7. Amputation
 Like most aspects
of the field of
medicince,
amputation has
greatly changed.
 In the 16th Century
→ there was no
anesthesia!
 Now, we have
general anesthesia
as well as very
realistic,
sometimes robotic,
limbs to replace
the diseased limbs.

8. Karen Anne Quinlan
 April 1975 – Karen Anne
Quinlan, 21 year old in
New Jersey – her friends
noticed she had stopped
breathing. They tried
mouth-to-mouth
resuscitation and called
an ambulance. She was
placed on a respirator
and feeding tubes. She
never regained
consciousness.

9. Karen Anne Quinlan
 After 3 months, her family came to accept that
Karen was not likely to regain consciousness.
 They talked over with their Catholic pastor their
desire to remove Karen from the respirator.
 He supported their decision based on the
judgment that continued use of the machine
would be extraordinary/disproportionate medical
treatment.
 Karen's physician at first agreed, but then had
“second thoughts,” fearing the risk of being
accused of euthanasia

10. Karen Anne Quinlan
 A lawyer advised the physician to obtain a
court order before turning off the respirator
 The hospital authorities did not want this
going to court
 The Quinlans insisted
 The New Jersey attorney general opposed
turning off the respirator
 The lower court agreed
 On appeal, however, the New Jersey
Supreme Court ruled in favor of the Quinlans,
and the respirator was turned off

11. Karen Quinlan
 Karen began to breathe
on her own!
 The issue of removing
the feeding tube was
never raised
 On January 13, 1986,
Karen Quinlan died of
pneumonia
 As a result of the court's
repeated concerns to
know the wishes of the
patient, interest in “living
wills” began

12. Clarence Herbert
 The first court case
dealing with the issue
of feeding tubes
 California, 1982 –
Clarence Herbert
suffered a cardiac
arrest and became
comatose
 The family authorized
the removal of the
respirator

13. Clarence Herbert
 Mr. Herbert began to breathe on his own!
 The family then, upon the recommendations of
the physicians involved, agreed to the removal
of his feeding tube
 A week after the feeding tube was removed, Mr.
Herbert died
 The two physicians involved were brought to
trial for homicide.
 The charges at first were dropped, then on
appeal they were found guilty, and then the
California appeals court reversed the decision.

14. 1983-1989
During these years, numerous court cases took
place dealing with requests to remove
feeding tubes.
 Claire Conroy
 Elizabeth Bouvia
 Paul Brophy
 Nancy Ellen Jobes
In all cases, the decision was made to allow
withdrawal of the feeding tube

15. Nancy Cruzan
 Then came the
case of Nancy
Cruzan
 In 1983, as the
result of a car
accident in
Missouri, Nancy
Cruzan was
severely brain-
damaged and left in
a PVS (Persistent
Vegetative State).

16. Nancy Cruzan
 Eventually her parents petitioned the court to
withdraw her feeding tube.
 A circuit court approved.
 However, the attorney general appealed the
decision to the Missouri Supreme Court.
 In November 1988, in a 4-3 decision, the
Court reversed the lower court's permission.
 In their decision, the court stated:

17. Nancy Cruzan
 “Nancy is not dead. Nor is she terminally
ill. This is a case in which we are asked to
allow the medical profession to make
Nancy die by starvation and dehydration.
The debate here is not between life and
death; it is between quality of life and
death... The state's concern with the
sanctity of life rests on the principle that life
is precious and worthy of preservation
without regard to its quality.”

18. Nancy Cruzan
 The Cruzan family then appealed to the United
States Supreme Court
 The Court upheld the Missouri ruling, but based
their decision on “informed consent” issues, stating
that there was no “clear and convincing evidence”
of the patient's wishes to remove nutritional support.
 The Cruzan family later obtained additional
statements from new witnesses who testified that
Nancy would not have wanted to be kept alive in a
comatose condition
 The feeding tube was removed and Nancy died on
December 26, 1990.

19. Terri Schiavo

20. What did the CMA say?
“Discontinuing nutrition and hydration in
this circumstance violates in its intention
the distinction between ‘causing death’
and ‘allowing death.’
“We can never justify the withdrawal
of sustenance on the basis of the
quality of life of a patient.”

21. Catholic Theologians Respond
 Catholic
theologians began
to take a closer look
at the issue of
removing feeding
tubes
 In 1986, a
committee of
eminent Catholic
moralists was set
up.
 They issued a
statement in 1987:

22. Catholic Theologians Respond
 “In our judgment,
feeding such patients
and providing them with
fluids by means of tubes
is not useless in the
strict sense, because it
does bring to those
patients a great benefit,
namely, the
preservation of their
lives and the prevention
of their death through
malnutrition and
dehydration...”

23. Catholic Theologians Respond
 “In the ordinary circumstances of life in our
society today, it is not morally right, nor ought
to be legally permissible, to withhold or
withdraw nutrition and hydration provided by
artificial means to the permanently
unconscious or other categories of seriously
debilitated but nonterminal persons. Rather,
food and fluids are universally needed for the
preservation of life and can generally be
provided without the burdens and expense of
more aggressive means of supporting life.”

24. Catholic Theologians Respond
The committee members did see exceptions to
the duty of providing nourishment and fluids
in two instances:
 1. if the patient's death was imminent
 2. if the patient was no longer able to
assimilate nourishment and fluids
Under these circumstances, continuation of
feeding would be useless and nonobligatory.

25. Pope Pius XII
 “Normally one is
held to use only
ordinary means –
according to the
circumstances of
persons, places,
times and culture –
that is to say,
means that do not
involve any grave
burden for oneself
or another.”

26. Pope Pius XII
 “A stricter obligation would be too burdensome
for most people and would render the
attainment of the higher, more important good
too difficult. Life, health, all temporal activities
are in fact subordinated to spiritual ends. On
the other hand, one is not forbidden to take
more than the strictly necessary steps to
preserve life and health, as long as one does
not fail in some more serious duty.”
 -address to Catholic physicians 24 Nov, 1957

27. Evangelium vitae
 Pope John Paul II tells us
that the only answer to
suffering lies in the Gospel
of Life as the only antidote
to the nihilism, self-delusion,
and despair of a society in
which oblivbion and death
are the panaceas for human
ills.
 This is where we cherish
life, our own as well as the
lives of others, as we
journey together on the path
to Eternity with God.

28. Food and Water
 Pope John Paul II spoke to
the Pontifical Academy for
Life and the International
Federation of Catholic
Medical Associations
 They asked him to speak
on “Life-Sustaining
Treatments and Vegetative
State.”
 He started his talk by
expressing his dislike for
the term “vegetative” to
describe a condition of a
human being, then he
went on to say:

29. Food and Water
 “I should particularly 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...”

30. Food and Water
 “The obligation to provide
the normal care due to the
sick in such cases
includes, in fact, the use of
nutrition and hydration...
The evaluation of
probabilities founded on
waning hope 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.”

31. From the “Ethical and Religious Directives
for Health Care Services (by the National
Conference of Catholic Bishops)
 “First, Catholic health
care ministry is rooted
in a commitment to
promote and defend
human dignity; this is
the foundation of its
concern to respect the
sacredness of every
human life from the
moment of conception
until death.”

32. What does the Catechism say?
 2278: “Discontinuing
medical procedures
that are burdensome,
extraordinary, or
disproportionate to
the expected
outcome can be
legitimate... Here
one does not will to
cause death; one's
inability to impede it
is merely accepted.”

33. What does the Catechism say?
 2279: “The use of
painkillers to alleviate
the sufferings of the
dying, even at the risk
of shortening their days,
can be morally in
conformity with human
dignity if death is not
willed as either an end
or a means, but only
foreseen and tolerated
as inevitable.”

34. What does the Magisterium of the
Catholic Church teach is “Ordinary?”
 Hope of benefit
 “Common use” (not
experimental or
exotic)
 “According to one's
status” (financially
and psychologically)
 Not difficult to use
 Not otherwise
unreasonable

35. Theology of the Body
We are not just a soul
trapped in an earthly
body. God’s gift of life is
the body and soul that
make up who we are.
Human life is such an
awesome gift of God, our
love of God and His
creation should prevent
us from ever even
considering suicide or
euthanasia.

36. Pope John Paul II
 In March 2004, Pope John Paul II affirmed
the findings of this committee when he stated
that the administration of food and hydration
to patients in a persistent vegetative state
was “a natural means of preserving life, not a
medical act.”
(The emphasis on natural means and medical
act are the original emphasis of Pope John
Paul II!)

37. Evangelium vitae
 Pope John Paul II's encyclical presents
Christ's compassion for the sick and dying,
the unborn, and the aged.
 He calls us to be compassionate as Christ
was compassionate to relieve suffering, but
always with respect for the inviolable sanctity
and dignity of all human life, however fragile,
young or old, sick or well.
 In this way we create a “Culture of Life.” If
not, we support a “Culture of Death.”

38. Ordinary vs. Extraordinary
In medicine, a treatment is ordinary if it is:
 1. scientifically established
 2. statistically successful
 3. reasonably available (can involve cost)
If any of these conditions is lacking, the
treatment is considered to be extraordinary

39. Ordinary vs. Extraordinary
In moral theology,
a treatment is
ordinary if it is:
 1. beneficial
 2. useful
 3. not
unusually
burdensome,
physically or
psychologically
(can involve
cost)

40. Forgoing extraordinary means
 A decision to forgo
extraordinary means
must rest on a
recognition that the
means of preserving life
or restoring health are no
longer beneficial, are no
longer useful, or are too
burdensome.
 It is not a decision that
the life of the patient is
no longer one worthy of
being lived.

41. What about when there is no
“reasonable hope for benefit?”
 “When inevitable death is imminent in spite of
the means used, it is permitted in conscience
to take the decision to refuse forms of
treatment that would only secure a precarious
and burdensome prolongation of life, so long
as the normal care due to the sick person in
similar cases is not interrupted.”
- “Declaration on Euthanasia” Vatican, 1980

42. What if I want to pursue
extraordinary care?
The Church teaches we are free to pursue
extraordinary care, and we may want to
especially if:
• We need more time to receive the Sacraments
of the Church
• To see friends or relatives one last time
• To be reconciled with somebody from whom we
have been estranged
• Or any other matter we may want to resolve
before we enter Eternity

43. Guidelines for making
prolongation-of-life decisions
 Competent patients must
judge whether a procedure
is extraordinary and
disproportionate in the
manner in which they
would make any serious
decision, i.e., with
consultation, reflection,
and prayer.
 Even though they judge a
treatment to be
extraordinary, they may
still conscientiously decide
to undergo it.

44. Imminent Death
When death is imminent one may refuse forms of
treatment that would only result in a precarious and
burdensome prolongation of life. There is a
presumption in favor of continuing to provide food and
water to the patient, but there is a stage in the dying
process when even these may no longer be obligatory
because they provide no benefit. Normal care always
remains morally obligatory, but refusal of additional
treatment when death is imminent is not equivalent to
suicide. It should be seen instead as an expression of
profound Christian hope in the life that is to come.

45. Dignity
 The word “dignity” is vitally important
 The advocates of euthanasia call for “death
with dignity”
 Within the Catholic tradition, dignity refers to
the excellence or nobility of the person
 Every human person possesses an inherent
dignity that must be respected and in no way
violated, even when such an individual may
not be fully competent or may have even
acted in evil ways.

46. What loss of dignity?
 Christian compassion helps
us to see that humans do
not lose their dignity
because of pain, physical
incapacity, helplessness, or
disfigurement.
 When people speak of loss
of the loss of dignity of the
dying person, they are really
talking about their own
reaction to the appearance
of the sick person.

47. There are many spiritual
causes of human suffering
 Alienation from healthy people
 Anger with God
 Feelings of guilt for being a burden to others
 Shame at one's physical appearance
 Weakness
 The anguish resulting from avoidance and
rejection by the world of the healthy

48. Dignity
 The dignity of the human
person lies in our being
created in the image and
likeness of God.
 A direct, willful violation
of any person is in some
sense an act of
sacrilege, doing violence
to the image of God, and
to that degree it
expresses contempt for
the person's Creator.

49. Redemptive Suffering
By virtue of our being made one with Christ in Baptism,
we can join our suffering to that of Our Savior
on the Cross at Calvary and thereby assist in
His work of salvation for the entire world.

50. Redemptive Suffering
The suffering of illness
and dying brings the
Catholic a grace-
filled opportunity to
offer prayer for
oneself, for loved
ones, and for the
whole human race.
Christ is with us
during our illness
and shares in our
suffering as we
share in His.

51. Christian Compassion
 As a virtue, Christian
compassion disposes us to do
all we can to relive the natural
course of suffering, but only in a
way that also helps the sufferer
to attain the ultimate good for
which humans were created –
union with God!
 Christian compassion calls on
us to recognize that suffering
comprises more than pain.

52. Via Dolorosa
 To kill the suffering
patient is to
interrupt his or her
way of the cross,
his or her journey
to salvation.
 It is to frustrate that
final abandonment
of self – body and
spirit – into the will
of the Creator.
Matthew 16:21-23
”Jesus began to show his disciples that he must go
to Jerusalem and suffer greatly… and be killed and
on the third day be raised. Then Peter took him
aside and began to rebuke him, “God forbid, Lord!
No such thing shall ever happen to you.”
He turned and said to Peter, “Get behind me,
Satan! You are an obstacle to me. You are
thinking not as God does, but as human beings do.”

53. Deathbed Conversions
 A human being
possesses dignity
always as a son
or daughter of
God.
 That dignity can
never be lost.
 A human death is
always the death
of a person with
dignity.

54. What will be the cause of death?
Whenever a recommendation is
made not to provide food and
water, one question to ask is:
“What will be the cause of
death?”
If the answer is dehydration and
starvation, and artificial
nutrition and hydration can be
easily supplied and
assimilated, then not supplying
them is a form of euthanasia.
Unconsciousness is not a fatal
disease. No one dies of
unconsciousness.

55. Another question to ask
Another question to
ask is whether the
dying process has
begun. If death is
imminent, the
provision of artificial
nutrition and
hydration is not
necessary. Death
will follow from the
underlying disease.

56. Patient Self-Determination Act of 1990
All hospitals and health care facilities are required by
law to provide written information to the patient about
the right to accept or refuse medical treatment and
the right to formulate an Advance Directive and/or
designate Durable Power of Attorney.
Important: You do not have to sign any Advance
Directive given to you by the hospital!

57. Two Kinds of Advance Directives
“Living Wills”
 Sometimes called “directive to physicians”
 A signed and witnessed statement giving
physicians instructions on whether to
withhold or withdraw medical treatment if a
person is unable to make the decision herself
or himself
 The idea of “Living Wills” was first formulated
in 1967 by the Euthanasia Education Council,
so in the beginning they were often suspect,
especially by religious groups

58. Criticisms of “Living Wills”
 1. too general to be useful
 2. lacking in adequate “informed consent”
because they are prepared in advance,
without reference to specific circumstances
 3. presumptuous that the average person
knows more about medical technology than
he or she actually does
 4. lacking in provision for the possibility of
future revision

59. Two Kinds of Advance Directives
“Durable Power of Attorney
for Health Care”
 In the business world, people often give a power
of attorney to other persons, authorizing them to
make decisions in their place
 That concept was carried over into health-care
decisions
 The key is to find someone with a similar
conscience and moral view who knows how you
would make decisions in various circumstances

60. Proxy decision guidelines
 Proxy representatives of
incompetent patients must
not hesitate to provide
ethically ordinary
treatment. Furthermore,
they may only forgo
extraordinary treatment
according to what they
know of the mind of the
patient or, lacking that
information, where sound
medical judgment indicates
that a competent person
would also forgo treatment.

61. What should you look for in
an Advance Directive?
The document should always uphold
these truths:
 The fundamental right to life
 The right to reasonable medical treatment
 The right to refuse medical treatment which is
disproportionate and extraordinary
 The immorality of euthanasia and assisted suicide
 The importance of communication between patient,
family, and physician

62. Advance Directives
There are many different living wills and advance
directives. Many invite patients to remove food and
water provided by artificial means if they should
become mentally incapacitated. Catholics should not
sign such documents. If they have signed them, they
should rescind them.

63. What does St. Paul say?
“If we live,
we live to the Lord,
and if we die,
we die to the Lord!”
- Romans 14:8

64. Evangelium vitae
“God alone has the power
over life and death. But
he only exercises this
power in accordance with
a plan of wisdom and
love. When man usurps
this power, being
enslaved by a foolish and
selfish way of thinking, he
inevitably uses it for
injustice and death. Thus
the life of the person who
is weak is put into the
hands of the one who is
strong; in society the
sense of justice is lost.”
Pope John Paul II, 1995

65. Prayer to St. Joseph
To thee I have recourse, St. Joseph,
Patron of the dying;
and to thee, at whose blessed death
watchfully assisted Jesus and Mary,
by both these dearest pledges
I earnestly recommend
the soul of this servant (handmaid)
in the sufferings of his (her) last agony,
that he (she) may by your protection
be delivered from the snares of the devil
and from eternal death,
and may merit to attain everlasting joy.
Through the same Christ our Lord. R.
Amen.

66. The National Catholic Bioethics Center
Provides a 24 hour
ethics consultation service,
free of charge
215-877-2660