SASKATOON — Making difficult health care decisions involves the same process we use to make other difficult decisions, ethicist Mary Deutscher said at a recent diocesan Foundations: Exploring Our Faith Together program hosted by Holy Spirit Parish in Saskatoon.
The ethicist for St. Paul’s Hospital and the Catholic Health Association of Saskatchewan engaged her listeners in a reflection on making decisions and the role of conscience, before addressing some specific scenarios related to artificial nutrition and hydration.
Deutscher led the crowd in brainstorming steps to take when making any difficult decision, listing such things as gathering information and facts, determining the effect on others, prayer, consultation with family and experts, weighing pros and cons, doing a “gut check” to see how you are feeling, checking your conscience, and taking a step back to reflect (as well as trying to make the decision when not under extreme stress).
All these decision-making strategies are helpful, but each person would have favourites, Deutscher noted, adding that the Catholic term we often use for this process is discernment.
Describing conscience as determining “what is it that God wants me to want,” Deutscher asked those present to discuss what conscience means to them: such as determining right from wrong, empathy for others, being at peace with something, listening to God’s will, and seeking a guiding light.
Deutscher then presented two excerpts from the Catechism of the Catholic Church to prompt discussion about what conscience means.
CCC #1776 states, “Deep within his conscience man discovers a law which he has not laid upon himself but which he must obey. Its voice, ever calling him to love and to do what is good and to avoid evil, sounds in his heart at the right moment,” Deutscher quoted. “His conscience is man’s most secret core and his sanctuary. There he is alone with God whose voice echoes in his depths,” states the catechism.
Deutscher described conscience as a calling: “It is not something that just makes you feel guilty after the fact, but it is a guide.”
The catechism also addresses the formation of conscience, stating in CCC #1784: “The education of the conscience is a lifelong task. From the earliest years it awakens the child to the knowledge and practice of the interior law recognized by conscience. Prudent education teaches virtue; it prevents or cures fear, selfishness and pride, resentment arising from guilt, and feelings of complacency, born of human weakness and faults. The education of the conscience guarantees freedom and engenders peace of heart.”
The church holds that a person’s conscience must be formed and educated. It is not always enough to rely on our “gut feeling,” said Deutscher. Then, in making a decision in conformity with an educated conscience, that “peace of heart” can be experienced.
Health care decisions often happen in a whirlwind, in a time of stress and confusion, fear or trauma. “You need to try and take a step back, and ask for as much time as you can, to try and find that peace of heart, and make an educated and informed decision,” said Deutscher.
It was noted that thinking about such decisions beforehand — such as in an advanced care directive — means discernment happens apart from the pressures of being in the midst of a health care crisis. The Catholic Health Association of Saskatchewan (CHAS) has published “A Faith-Based Advance Directive For Health Care” as a tool to assist with such discernment.
Using the example of artificial nutrition and hydration — often referred to as a “feeding tube” — Deutsher explored decision-making factors that would help determine whether a treatment is deemed ordinary or beyond-the-ordinary, a benefit or a burden.
Intravenous (IV), Nasal Gastric (NG), Percutaneous Endoscopic Gastrostomy (PEG), and Total Parenteral Nutrition (TPN) are among the methods for artificially providing hydration and nutrition — and each method has its own particular applications, benefits and risks. Some methods are used as a short intervention, to assist someone in getting healthier, while others are more long-term.
Making a decision about continuing or terminating a particular form of artificial hydration or nutrition would involve a similar discernment to other kinds of decisions, said Deutscher.
She also provided excerpts from church documents examining the provision of food and drink to patients, and when it might be morally acceptable to withdraw what is usually deemed to be ordinary care.
As early as the 16th century the question came up as to whether a dying man is committing suicide if he refuses to eat. “Many people stop being interested in food when they are dying; they stopped wanting to eat,” Deutscher said. “They noticed this and took the time to seriously think about it.”
One theologian, Francisco de Vitoria (1483 - 1546), maintained that, if a dying person refused food and drink ,“it was because he was now focusing on non-earthly things, and should not be considered suicidal,” Deutscher related.
De Vitoria wrote: “If a sick person is able to take nourishment, the hope of life, he has an obligation to take it, just as he must be given it, if he is not able to do so himself. However, if the decline of the spirit is so great, and the alteration of appetite is so much so that the infirm is able to take nourishment only with great trouble and an almost certain torment, then it can be considered an impossibility and one is excused from sin . . . especially if there is little or no hope for life.”
The statement recognizes that food ordinarily is a good thing, and if someone is simply sick and needs food, we have a moral obligation to provide it, said Deutscher. “But he also says that in certain circumstances it might not be what the person needs.”
She also referred to the 1957 words of Pope Pius XII about ventilators, in which he made a distinction between ordinary and extra-ordinary measures, putting ventilators into the “extra-ordinary camp” as something that were good to use if they help a person, but that there was no obligation to keep people on ventilators. It is not that the treatment is “good or bad” but whether it is proportionate or disproportionate, said Deutscher.
“When it comes to medical interventions, there are things that are ordinary and expected, and you also have things that are outside that ‘ordinary’ box that you accept — it doesn’t mean that they (the ‘extra-ordinary’) are good or bad, it is just not what you might normally expect.”
Medical interventions such as ventilators and feeding tubes are not good or evil in themselves, they are tools, she said. “It’s like asking if a hammer is good or evil,” she said. “It depends on the circumstances, and how you use a tool that makes it good or bad.”
The group then discussed what treatments in our society are considered ordinary and which might be deemed extra-ordinary. For instance, a cast is ordinary treatment in this time and place. However, something like chemotherapy might go into either category, depending on circumstances.
Food is usually concerned ordinary care or treatment, but at the same time, “there might be circumstances in which food might make the jump to being something extra-ordinary,” Deutscher noted.
She then explored the Terry Schiavo case: a woman with an acquired brain injury who was in a persistent vegetative state, whose husband argued she would not want to have been kept on prolonged life support, and decided to remove her feeding tube. Schiavo’s parents disputed his decision, and there were seven years of legal challenges before the tube was removed. The focus of the case was on who had the right to act as her proxy decision-maker, with the courts ultimately deciding it was her husband.
“So on March 18, 2005, Terry Schiavo’s feeding tube was removed. She died on March 31, 13 days later. Her parents and her brother described it as death by starvation, and the Catholic Church agreed,” Deutscher said. “This led to a lot of confusion for a lot of people, and many asked the question, ‘Is the church saying that feeding tubes are mandatory now?’ ’’
The bishops of the United States wrote the Vatican and asked them to clarify the position on the case and on feeding tubes. In the first part of the response, the Congregation for the Doctrine of the Faith described food as a basic requirement of life.
“In the case of Terry Schiavo, she wasn’t dying — she was still processing food, food was still doing its designed end, keeping her alive. It really didn’t matter how brain damaged or not that she was — she was still a human being and had a fundamental right to receive food,” Deutscher summarized.
“But it didn’t stop there. They (the Congregation for the Doctrine of Faith) did not want people to simply think that feeding tubes were mandatory, that everyone has to have a feeding tube, so after six and a half pages of saying why food is ordinary, they give some circumstances where food might be considered extra-ordinary,” she said.
The 2007 Commentary on Artificial Nutrition and Hydration acknowledged that in remote places or in situations of extreme poverty, the artificial provision of food and water may be physically impossible, and no one is held to the impossible.
The congregation also wrote: “Nor is the possibility excluded that, due to emerging complications, a patient may be unable to assimilate food and liquids, so that their provision becomes altogether useless.”
For instance, artificial feeding would not be a benefit if a person is nearing the end of life, and their organs have shut down, and they are not processing anything, described Deutscher. “Or someone who is dying may be swelling a lot — that may be a sign that their body is retaining that water, and if you keep pumping it into them it is not going to get the job done” and may make their suffering greater.
Finally, the congregation addressed the possibility that providing food might in some cases be more burdensome than beneficial, saying, “The possibility is not absolutely excluded that, in some rare cases, artificial nourishment and hydration may be excessively burdensome for the patient or may cause significant physical discomfort, for example resulting from complications in the use of the means employed.”
Deutscher then led the gathering in a discussion of three scenarios involving artificial nutrition and hydration, weighing the burdens and the benefits to determine if the care would be considered ordinary or extra-ordinary, and whether artificial nutrition and hydration might be morally and ethically withdrawn.