Transcript The Ends of Life and Death: Public Policy, Spirituality, & Law

The Catholic Tradition of A
Good Death: Emerging
Implications
Nuala Kenny SC OC, MD, FRCP
Professor Emeritus
Department of Bioethics
Dalhousie University
Ethics & Health Policy Advisor
Catholic Health Alliance of Canada
A Good Death
“Where, O death, is your victory? Where, O
death, your sting?
In This Reflection I Plan to:
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Consider the context of dying today
Reflect on the Catholic tradition of a ‘good
death’
Identify some lessons regarding health
decisions and end of life care for:
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Persons and their loved ones
Professionals
Parishes
Public policy
Dying in North America
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We are a death-denying, death-defying
culture
¼ million die each year; 75% over 65yrs
75% die in hospital and long term care;
majority under aggressive treatment for cure
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Catholics are among the most likely to be still
undergoing aggressive treatment at death!
5-10% receive integrated palliative end of life
care
Confusion re A Good Death
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Polls show confusion about end of life care, patients’
rights and duties and the goals and effectiveness of
palliative care, especially
 Refusal of care
 Withdrawal/withholding on non-beneficial care
 Pain and symptom control
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There are different visions of a ‘good death’
 Assisted death-euthanasia and assisted suicide
 Modern hospice and palliative care
 The long Catholic tradition
“Whoever lives and believes
in me shall never die” John 11:26
The Long Catholic Tradition on
Health Care Decisions (Since 16thC)
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Life and physical health are precious gifts
entrusted to us by God. We must take
reasonable care of them, taking into account
the needs of others and the common good.
Catechism
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#2288
If morality requires respect for the life of the
body, it does not make it an absolute value.
Catechism
#2289
The Long Catholic Tradition on
Health Care Decisions (Since 16thC)
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If morality requires respect for the life of the
body, it does not make it an absolute value.
Catechism
#2289
Pope Pius XII 1957
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“(N)ormally one is held to use only ordinary
means-according to circumstances of
persons, places, times and culture-that is to
say, means that do not involve any grave
burden for oneself or another. A more strict
obligation would be too burdensome for most
men 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.”[14]
CDF 1980 Declaration on Euthanasia
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“It will be possible to make a correct
judgment as to the means by studying the
type of treatment to be used, its degree of
complexity or risk, its cost and the
possibilities of using it, and comparing these
elements with the result that can be
expected, taking into account the state of the
sick person and his or her moral
resources.”[15] .
Relief of Pain and Suffering
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“While pain and suffering are to be relieved at
all cost, when accepted in faith suffering
does have redemptive value…This does not
mean that God takes pleasure in human pain
and suffering. Nor does it mean that
Christians are to be passive in accepting
suffering and not to strive to alleviate or
eradicate it at its source”
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Catholic Health Ministry and the Catholic Church in Canada, no.7
Nutrition and Hydration: Special Concerns
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Confusion about the obligation to
take/provide medically assisted nutrition and
hydration, especially at end of life
Special concerns re nutrition and hydration :
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Social and ethical significance of feeding
Anorexia at the end of life is normal
The importance of non-abandonment and ordinary
care
The 2004 Papal Allocution
The 2004 Papal Allocution
“…the administration of water and food, even
when provided by artificial means, always
represents a natural means of preserving
life and 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 achieved its proper
finality, which in the present case consists
in providing nourishment to the patient
and alleviation of his suffering.”(no4)
US Bishop’s Clarification
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“In principle, there is an obligation to provide
patients with food and water, including
medically assisted nutrition and hydration for
those who cannot take food orally. This
obligation extends to patients in chronic and
presumably irreversible conditions (e.g., the
“persistent vegetative state”) who can
reasonably be expected to live indefinitely if
given such care.
Clarification con’t
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Medically assisted nutrition and hydration become
morally optional when they cannot reasonably be
expected to prolong life or when they would be
‘excessively burdensome for the patient or (would)
cause significant physical discomfort, for example
resulting from complications in the use of the means
employed.’
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For instance, as a patient draws close to inevitable
death from an underlying progressive and fatal
condition, certain measures to provide nutrition and
hydration may become excessively burdensome and
therefore not obligatory in light of their very limited
ability to prolong life or provide comfort (ERD # 58).
Accepting limits
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“Human life, however, has intrinsic
limitations, and sooner or later it ends in
death. This is an experience to which each
human being is called, and one for which he
or she must be prepared”
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Pope Benedict XVI Message for the World Day of the
Sick February 11, 2008
Accepting Death & The Limits of
Medicine
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When death is clearly imminent and
inevitable, one can in conscience “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”
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Declaration on Euthanasia “Iura et Bona” 1980
Refusal of Non-beneficial &
Unduly Burdensome Care
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“ To forego extraordinary of disproportionate
means is not the equivalent of suicide or
euthanasia; it rather expresses acceptance of
the human condition in the face of death”
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John Paul II Evangelium Vitae,no.66 1995
Rejecting Euthanasia and Assisted Suicide
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“ Euthanasia is a false solution to the drama
of suffering, a solution unworthy of man.
Indeed, the true response cannot be to put
someone to death, however ‘kindly’ but rather
to witness to the love that helps people to
face their pain and agony in a human way”
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(Pope Benedict XVI, Angelus message 1 February,
2009)
So, in summary
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Life is a basic but limited good; we have an
obligation to protect and preserve prudently
The obligation to prolong life is evaluated in
light of one’s medical condition and ability to
pursue the spiritual goods of life
The determination of benefit and burden
belongs to the patient
Summary con’t
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We are morally obliged to use medical means
that offer reasonable hope of benefit without
imposing excessive burden
We are not obliged when death is imminent
and medicine only prolongs the dying; there
is no reasonable hope of benefit or treatment
imposes excessive burden
Burden is understood broadly-physical,
psychological, social and spiritual
We accept suffering; we work toward pain
and other physical symptom alleviation
Some cases:
Pope John Paul II
Implications and Lessons
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For individuals
For their loved ones
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For professionals who care for the dying
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For communities and parishes
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For public policy
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For individuals and their loved ones
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We need to take prudent care of our life and
health
We should take informed (prayerful)
decisions
Refusal of Rx by competent patients allowed
We should see advance care planning as
primarily a spiritual event
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Clarifying values
Conversation, conversation
Make an advance directive
For professionals who care for the
dying
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The importance of care and nonabandonment
Respect for spiritual/religious values
Withdrawal/withholding of nonbeneficial/burdensome Rx is allowed
Application of the goals of palliative care:
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Pain and symptom control
Support for the ‘last things’
Concern for family and loved ones
Importance of ‘presence’ and non-abandonment
For communities and parishes
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We all have an obligation to care for the sick,
the dying and their care-givers
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We assume professional caregivers and
services will do everything
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Parish pastoral care for the sick,
handicapped, dying, bereaved is a crucial
element in our understanding of community
For public policy
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POLST vs advance care planning
Legalization of assisted death
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Hospice & Palliative care as national priority
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Understand the consequences of legal change
Advocate for improvement in access & quality
Concern re the privatization (profitization) of end
of life care
Support for caregivers
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Crucial need for options and for respite care
Principle of Double Effect
continued
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There are two effects, one good and
one bad; the action is good in itself.
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one sincerely intends to produce the good
effect
the good effect is not achieved through the
bad effect
the good intended is proportionately greater
than the bad that is foreseen but not
intended
Important Issues with PDE
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Morality is not entirely dependent on
consequences
Intention is important
Intention is not belief or desire
Intention is not motive
Dosage, intention and action
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‘Screening questions’ for intent