Article 1: PROLONGING LIFE OR POSTPONING DEATH?
FAUSTO GOMEZ OP
John is 48 years old. He is terminally ill with brain cancer – and suffering terribly. His older brother who is a physician has accepted, and convinced John, that euthanasia is unethical and unchristian. Now the only daughter of John cannot accept his approaching death, and wants to continue treatment by all means available. Out of love for her, her father has consented to start aggressive treatment. Now the physician asks: May I give to my brother all the medical means available to keep him alive?
The doctor is asking for what is called dysthanasia. Is dysthanasia ethical and Christian?
MEANING OF DYSTHANASIA
What is dysthanasia? Etymologically, dysthanasia means faulty, imperfect death. It may be defined as the medical process through which the moment of death is postponed by all means available. Dysthanasia is the undue prolongation of life – of dying -, the postponement of death.
The fundamental ethical distinction to apply in the case of the terminally ill is the distinction between ordinary and extraordinary means of treatment. In the words of the National Conference of American Bishops (USA), ordinary or proportionate means “are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community.” On the other hand, extraordinary or disproportionate means refer to “those that in the patient’s judgment do not offer a reasonable hope of benefit or entail an excessive expense on the family or the community.” This important distinction should be applied fairly and not in a discriminatory manner – in a different way for rich and poor, for men or women, for children and the elderly, for the able and the differently able.
Another important and enlightening distinction on the case refers to the kind of treatment, which can be beneficial, useless or doubtful. If the treatment is beneficial it must be generally given, except when it is too burdensome for the patient or the family. Useless treatment is futile treatment, which is not really beneficial but futile. When the doctor is not sure if it is beneficial or useless, the treatment is called doubtful treatment.
MORALITY OF DYSTHANASIA
Human life must be protected and dutifully prolonged. From a humanist and Christian perspective, human beings are obliged to take care of and prolong their lives through ordinary, proportionate, beneficial means. It is our duty to care for our life and try to be healthy. For believers in God, the use of beneficial treatment is connected with the principle of stewardship, which states that we are stewards of our life which belongs to God, our creator, who is the Lord of life and death.
When the medical treatment is doubtful or uncertain, the “best-interest of the patient” principle seems to demand providing treatment, which has a potential benefit – to health and life.
When the treatment is futile, or too burdensome, it is not obligatory to use it, but generally optional. However, it appears more humane and Christian not to try a useless therapy. Indeed, if it is truly useless, why should it be used at all? The poet Jorge Manrique wrote: Que querer hombre vivir / cuando Dios quiere que muera / es locura (“For man to want to live when God wants him to die is madness”). Therefore, death should not be caused, neither should it be absurdly delayed (Spanish Episcopal Conference). St. John Paul II said: “Both the artificial extension of human life and the hastening of death, although they stem from different principles, conceal the same assumption: the conviction that life and death are realities entrusted to human beings to be disposed of at will.”
When facilities are scarce, when the poor do not have primary health care, may we squander funds and resources by providing futile high-tech procedures? The use of extraordinary means is at most optional and, at times, it may be obligatory not to use them. In some cases – or more than some -, it may also be against social justice: medical resources are limited and ought to be used rationally and ethically by those who really need them. Furthermore, very often the use of extraordinary means entails for the patient, who is hooked to machines and heavily intubated with multiple tubes, an incredible isolation from his or her loved one.
Dysthanasia is generally unethical because it is not the due prolongation of life, but the undue postponement of death, which usually ends up in an “undignified death,” after an abusive use of extraordinary means of treatment, provoked by the technological imperative. The doctor is obliged to treat, but not to over-treat.
Another basic question: Who decides to use or not use disproportionate means of treatment? When possible, the patient gives informed consent: the patient gives free and responsible consent after knowing and understanding his medical facts, treatments available to him and their consequences). When not possible, proper surrogates (the closest relative or the family representative) provide proxy or substitute consent, which must respect the principle of the best interest of the patient.
THERE IS A TIME TO LIVE AND A TIME TO DIE
The daughter of John is really asking for the undue prolongation of life, for the continuation of artificial life for her dear father. Life has a beginning and an end for all humans. There is a time to live. Last medical report: John’s terminal cancer of the brain has metastasized to other parts of his body. The daughter is asking for the postponement of his death through useless and futile means of treatment. For each one of us, there is a time to die (Ecl3:2), neither earlier through euthanasia, nor later through dysthanasia.
Another major point! Objectively speaking, the ethical principles are clear and neat – and helpful. The problem is we are speaking of subjects, of persons, of a concrete persons, of John who has a loving daughter, and a brother who is a doctor. We cannot leave John with cold bioethical principles and their application to his case. Against his pains, doctors give painkillers. Against his loneliness, the daughter and the “significant “others” offer love, solidarity and compassion. Accompaniment and love will also aid John’s daughter. Praying with him and for him is a fraternal Christian duty.
We add a final significant point: our humanity and our faith urge us to defend life. We respect people with different stands on the matter.
The elder brother of John, the physician should not provide his younger brother John with extraordinary means of treatment. What else can he do for John? In our next conversation we hope to share with you, dear reader, some more thoughts on this sensitive matter. Until then take it easy, be compassionate – and smell the flowers on your way!
(Published by O Clarim, June 2, 2017)
Article 2: ORTHOTHANASIA OR ALLOWING TO DIE
FAUSTO GOMEZ OP
Our friend John is dying of metastatic terminal brain cancer. His elder brother, a physician is helping him face, as a human being and as a Christian, his complicated situation. After rejecting the options of euthanasia and dysthanasia as unethical, the doctor offers his brother John the option of orthothanasia, or allowing to or letting him die.
Is orthothanasia, or allowing to die ethical?
MEANING OF ORTHOTHANASIA
The word orthothanasia was used for the first time in the 1950s. It means correct dying, or allowing to die or letting die.
It is vital to note the difference between allowing death to occur and intending death to happen. While in euthanasia the death of the patient is directly intended and caused, in allowing to die his death is directly caused by a grave pathology: the morphine administered to the patient in pain directly causes the relief of his pain and indirectly and unintendedly may perhaps advance his death, which is merely foreseen and tolerated.
Let us underline that in the case of letting die, what is directly intended is the relief of the acute pain of the patient. In allowing to or letting die, therefore, death is neither directly caused nor intended or postponed. It merely happens. It is an event, part of the temporal life of every human being. Hence, allowing to die is anti-euthanasia, which unethically anticipates death, and anti-dysthanasia, which unduly postpones it.
ALLOWING TO DIE: POSSIBILITIES
Allowing to die includes, in particular, three possibilities.
First possibility: when the treatment to prolong life is useless or futile for the patient, and therefore ought not to be given. We remember the world of the poet: For man to want to live when God wants him to die is madness.
Second possibility for letting die: when the prolongation of life or the postponement of death is unduly burdensome in the first place for the patient – also for the family. On this point, the Catechism of the Catholic Church summarizes the traditional teaching of the magisterium: “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” (CCC, 2278).
Third possibility for allowing to die: when the patient needs painkillers or medical sedation, which does not intend the death of the patient. These painkillers directly mitigate suffering and indirectly may shorten life. Physicians and significant others are committed to relieve pain and suffering, which is their professional commitment, or moral duty limited only by the prohibition against direct killing. Summing up the traditional teaching of the Church, the Catechism states: “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” (CCC, 2279).
Related to the option of allowing to or letting die, we usually face, among others, three objections: one objection refers to doubtful treatment, another to the real meaning of death with dignity, and the third to patients in persistent vegetative state (PVS).
How about a doubtful treatment? If treatment is beneficial to the patient and not unduly burdensome, it ought to be given: we are to administer our life well. If treatment is truly useless, generally it should not be given. Moreover, if the treatment is doubtful or uncertain, the “best-interest of the patient” principle suggests providing treatment for it might have a potential benefit: in doubt, it is good to be on the side of life.
“DEATH WITH DIGNITY”
Another objection is: How may we understand ‘death with dignity’? It is often understood wrongly as “death without pain,” as if those who die with pain cannot have a death with dignity. The word dignity is often – as someone put it – “high-jacked” by those who favor euthanasia. For believers and others, to die with dignity means respect for the dying, preparing for death and accepting it when it comes. The saintly Pope John Paul II says that the elderly – and all human beings – have “the right to a worthy life and to a worthy death.” Palliative or comfort, or hospice are is a way to a worthy death, or a death with true dignity.
Death with dignity then is an ambiguous expression that may mean two opposite things. One meaning is the justification of killing – of euthanasia and assisted suicide – based upon the unethical principle of absolute personal autonomy. A second meaning is this: “letting die in peace” or allowing to die, which is ethical. Death with dignity means for the Christian a good and dignified death that respects the principles of stewardship (God is the Lord of Life and Death), of solidarity (we are members of the human family and God’s family), and the principle of respect for all persons, beginning with the respect due to our own person, dignity and rights, including the basic right to life, which ends with a dignified death. Palliative care helps achieve a death with dignity that is, a death that comes after achieving peace with God, with ourselves, loved ones, and neighbors.
The final objection we wish to face: How about patients in deeply comatose or a persistent vegetative state (PVS)? What kind of treatment should they be given? The main problem here is reliable and true diagnosis: How certain may we be of the diagnosis? Certainly, these permanently comatose patients have to be given beneficial and not too aggressive or undue burdensome treatment. Food and drink should always be given. These are not medical treatment, but a human need of every person. The basic teaching of the Church is well formulated by the American Bishops (USA) in their significant Ethical and Religious Directives for Catholic Health Care Services: “There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient.”
A final radical question: Is there any equivalence between killing and allowing to die? There is, indeed, no equivalence at all but profound difference between killing and allowing to die: while killing is intrinsically and objectively evil, allowing to die is the moral option that respects life and considers death as inevitable part of human life.
Most probably our patient John is soon to die of metastatic brain cancer. So far three options were presented to him: assisted suicide, prolonging dying with useless aggressive treatment, and allowing him to die with dignity. From a humanist and Christian perspective, the ethical possibility is the third, which is allowing or letting him to die. (In parenthesis: When we are in doubt regarding the application of the ethical guidelines at the end of our own life and the life of our loved ones, we ask those who may know better than us. However, we decide on our own cases; others advise but should not decide for us)
Our dear patient John is asking his brother physician: “Please, let me die in peace, but remove or at least decrease substantially my terrible pains.” John is asking for comfort or palliative care. What is the meaning and implications of palliative care? We shall try to answer this question in our next conversation with our dear readers. Many thanks for walking with us.
(Published by O Clarim, June 9, 2017)