Vatican reaffirms, clarifies church teachings on end-of-life care

VATICAN CITY — With the legalization of assisted suicide and euthanasia in many countries, and questions concerning what is morally permissible regarding end-of-life care, the Vatican's doctrinal office released a 25-page letter offering "a moral and practical clarification" on the care of vulnerable patients.

"The church is convinced of the necessity to reaffirm as definitive teaching that euthanasia is a crime against human life because, in this act, one chooses directly to cause the death of another innocent human being," the document said.

Titled, "'Samaritanus bonus,' on the Care of Persons in the Critical and Terminal Phases of Life," the letter by the Congregation for the Doctrine of the Faith was approved by Pope Francis in June, and released to the public Sept. 22.

Read the full text of “‘Samaritanus bonus,’ on the Care of Persons in the Critical and Terminal Phases of Life”

A new, "systematic pronouncement by the Holy See" was deemed necessary given a growing, global trend in legalizing euthanasia and assisted suicide, and changing attitudes and rules that harm the dignity of vulnerable patients, Cardinal Luis Ladaria, congregation prefect, said at a Vatican news conference Sept. 22.

It was also necessary to reaffirm church teaching regarding the administration of the sacraments to and pastoral care of patients who expressly request a medical end to their life, he said.

"In order to receive absolution in the sacrament of penance, as well as with the anointing of the sick and the viaticum," he said, the patients must demonstrate their intention to reverse their decision to end their life and to cancel their registration with any group appointed to grant their desire for euthanasia or assisted suicide.

In the letter's section on "Pastoral discernment toward those who request euthanasia or assisted suicide," it said a "priest could administer the sacraments to an unconscious person 'sub condicione' if, on the basis of some signal given by the patient beforehand, he can presume his or her repentance."

The church's ministers can still accompany patients who have made these end-of-life directives, it added, by showing "a willingness to listen and to help, together with a deeper explanation of the nature of the sacrament, in order to provide the opportunity to desire and choose the sacrament up to the last moment."

It is important to carefully look for "adequate signs of conversion, so that the faithful can reasonably ask for the reception of the sacraments. To delay absolution is a medicinal act of the church, intended not to condemn, but to lead the sinner to conversion," it said.

However, it added, "those who spiritually assist these persons should avoid any gesture, such as remaining until the euthanasia is performed, that could be interpreted as approval of this action."

Chaplains, too, must show care "in the health care systems where euthanasia is practiced, for they must not give scandal by behaving in a manner that makes them complicit in the termination of human life," the letter said.

Another warning in the letter regarded medical end-of-life protocols, such as "do not resuscitate orders" or "physician orders for life-sustaining treatment" and any of their variations.

These protocols "were initially thought of as instruments to avoid aggressive medical treatment in the terminal phases of life. Today, these protocols cause serious problems regarding the duty to protect the life of patients in the most critical stages of sickness," it said.

On the one hand, it said, "medical staff feel increasingly bound by the self-determination expressed in patient declarations that deprive physicians of their freedom and duty to safeguard life even where they could do so."

"On the other hand, in some health care settings, concerns have recently arisen about the widely reported abuse of such protocols viewed in a euthanistic perspective with the result that neither patients nor families are consulted in final decisions about care," it said.

"This happens above all in the countries where, with the legalization of euthanasia, wide margins of ambiguity are left open in end-of-life law regarding the meaning of obligations to provide care."

The church, however, "is obliged to intervene in order to exclude once again all ambiguity in the teaching of the magisterium concerning euthanasia and assisted suicide, even where these practices have been legalized," it said.

Euthanasia involves "an action or an omission which of itself or by intention causes death, in order that all pain may in this way be eliminated."

Its definition depends on "the intention of the will and in the methods used," it added.

The letter reaffirmed that "any formal or immediate material cooperation in such an act is a grave sin against human life," making euthanasia "an act of homicide that no end can justify and that does not tolerate any form of complicity or active or passive collaboration."

For that reason, "those who approve laws of euthanasia and assisted suicide, therefore, become accomplices of a grave sin that others will execute. They are also guilty of scandal because by such laws they contribute to the distortion of conscience, even among the faithful."

The letter also underlined a patient's right to decline aggressive medical treatment and "die with the greatest possible serenity and with one's proper human and Christian dignity intact" when approaching the natural end of life.

"The renunciation of treatments that would only provide a precarious and painful prolongation of life can also mean respect for the will of the dying person as expressed in advanced directives for treatment, excluding however every act of a euthanistic or suicidal nature," it said.

However, it also underlined the rights of physicians as never being "a mere executor of the will of patients or their legal representatives, but retains the right and obligation to withdraw at will from any course of action contrary to the moral good discerned by conscience."

Other aspects of end-of-life care the letter detailed included: the obligation to provide basic care of nutrition and hydration; the need for holistic palliative care; support for families and hospice care; the required accompaniment and care for unborn and newly-born children diagnosed with a terminal disease; the use of "deep palliative sedation"; obligation of care for patients in a "vegetative state" or with minimal consciousness; and conscientious objection by health care workers.

— Carol Glatz, Catholic News Service

What kind of legal documents or arrangements about your end-of-life medical care should you have?

An “Advance Medical Directive” and “Durable Power of Attorney for Health Care” (or “Health Care Proxy”) are legal documents that take effect if the patient becomes incompetent.

Even though these documents can be written without the assistance of an attorney, some states give them considerable legal weight.

An Advance Medical Directive specifies what medical procedures the patient wishes to receive or to avoid. (An Advance Medical Directive sometimes is called “A Living Will,” but because of its association with the advocacy of euthanasia, we have chosen to avoid this phrase.)

Durable Power of Attorney specifies a particular individual (variously called a “proxy,” “agent,” or “surrogate”) to make medical decisions on behalf of the patient (or the “principal”) when the patient is no longer able to do so.

When neither of these instruments is drawn up, the task of making important medical decisions usually falls to the family.

Most states have laws governing the use and implementation of the Advance Medical Directive and Durable Power of Attorney.

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. The health care facility must also provide written policies stating how the patient’s Advance Directive or Durable Power of Attorney will be implemented. People should remember that they do not have to sign any Advance Directive given to them by the hospital.

WHICH ONE SHOULD YOU CHOOSE?

Make certain that your Advance Directive forbids any action that the Catholic faith considers to be immoral, such as euthanasia or physician-assisted suicide. (A Catholic hospital, in any case, will not follow a directive that conflicts with Church teaching.)

Once a directive is made, copies should be distributed to the agent and anyone else the patient deems appropriate. One should periodically review the provisions of an Advance Directive and, when there is a revision, all previous copies should be destroyed.

The usefulness of an Advance Directive, which gives specific instructions for care, is limited because of its inflexibility. If circumstances change significantly between writing the Advance Directive and its implementation, the instructions may be of little value to those acting on a patient’s behalf, or may even hinder their freedom to make good decisions. There may also be a problem of interpreting the document when it is not clearly written. An Advance Directive oftentimes does not allow for adequate informed consent because one must make a decision about a future medical condition which cannot be known in advance.

When drawing up an Advance Directive, therefore, one should focus on general goals rather than on specific medical procedures.

Assigning Durable Power of Attorney is preferable to an Advance Directive because it leaves decisions in the hands of someone whom the patient has personally chosen.

A proxy agent also can be more sensitive and responsive to the decision-making that is necessary for a given case. When assigning Durable Power of Attorney one should choose an agent of good moral character – someone who is known to be capable of making sound decisions under stressful circumstances. The agent should know the teachings of the Church and possess the practical wisdom to apply them to changing circumstances.

An agent, of course, must also survive the patient. One may designate alternate agents in case one’s first choice, for some reason, is unable to act.

A good agent makes decisions for the patient in light of what the patient would choose if able to do so. The proxy, therefore, should be very familiar with your moral convictions and wishes. When there is an Advance Directive from you, this should be the guide. When there is not, the agent must act on the oral instruction that has been given. Sometimes, however, acting in your best interests means ignoring instructions that are obviously unwarranted or clearly immoral. No agent is bound to carry out actions that conflict with morality and the faith.

ALSO NOTE

When formulating any Advance Directive and discussing end-of-life issues, avoid using the expression “quality of life” because it is used by advocates of euthanasia to suggest that some lives are not worth living.

While illness and other circumstances can make life very difficult, they cannot diminish the inestimable worth of each human life created by God. Life itself is always a good, and is a quality that can never be lost. Still, we need not cling to this life at all costs (what’s called “therapeutic obstinacy”), since the life to which we have been called in Christ is incomparably better.

Euthanasia has been defined by St. John Paul II in “The Gospel of Life” as “an action or omission which of itself and by intention causes death, with the purpose of eliminating all suffering.” Supporters of euthanasia often justify it or physician-assisted suicide on the grounds that the pain of terminal illness is too great for the average person to bear. They hold that it is more merciful to kill the suffering patient. However, the Church holds that “euthanasia is a grave violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person.”
— National Catholic Bioethics Center

More online

At www.ncbcenter.org: What are the Church’s teachings on end-of-life decisions and how difficult will it be to follow them? Must we endure a great deal of pain? What if I am no longer able to make medical decisions for myself? Order or download a copy of “A Catholic Guide to End-of-Life Decisions,” which describes how you might approach end-of-life decisions in light of the teachings of the Church.

Ordinary/proportionate versus extraordinary/disproportionate means of preserving life

Ordinary or proportionate means are those that (in the judgment of the patient assisted by health care professionals) offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community. A person has a moral obligation to use ordinary means.
Extraordinary or disproportionate means are those that (in the judgment of the patient assisted by health care professionals) do not offer a reasonable hope of benefit, do entail an excessive burden, or do impose excessive expense on the family or the community. A person may forgo extraordinary means.
Euthanasia and assisted suicide
Euthanasia is an act or omission that of itself or by intention causes death to alleviate suffering. Catholics may never condone or participate in euthanasia or assisted suicide in any way.
Dying patients who request euthanasia should receive loving care, psychological and spiritual support, and appropriate remedies for pain and other symptoms so that they can live with dignity until the time of natural death.

Nutrition and hydration
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.
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.
— National Catholic Bioethics Center. Learn more online at www.ncbcenter.org.

What is the difference between foreseeing death and intending death?

The difference ultimately lies in the intentionality of the patient or health care professional. A person should never intend in any way the death of a patient or the hastening of a patient’s death. Sometimes it is difficult to determine whether a medical decision made during end-of-life care includes such an intention. Certain means can be used to alleviate a patient’s pain, for example, by a physician who foresees that the patient’s life may be shortened as a result (as an indirect, non-intended but tolerated effect of the therapy), but similar means could be used to intentionally shorten a patient’s life.

Are proportionate or ordinary means the same for everyone?

Basic care (such as nutrition and hydration, pain relief, antibiotic treatment, and postural change) is generally the same for all patients and should always be provided. The evaluation of proportionate or disproportionate means, however, is based on objective and subjective factors for an individual patient. For example, total parenteral nutrition may be a proportionate means in an industrialized country but a disproportionate means in a developing country, where it is not affordable or is technically too difficult to administer. A treatment may also be disproportionate because it is futile or because it causes complications that are too hard for the patient or the patient’s family to bear.

What ethical problems are there with advance directives?

The right of patients to self-determination can lead them to include morally illicit requests in advance directives, such as requests to have ordinary care withdrawn.
An effective therapeutic alliance between a physician, a patient and the patient’s proxy is the best way to address end-of-life issues. Requests made by a patient in an advance directive may preclude therapeutic dialogue, preventing such an alliance.

A patient may react to an illness or a specific therapy differently than expected, or medical advances occurring after a directive was written may change the patient’s treatment options in unexpected ways. In such situations, an advance directive may prevent objective moral analysis.

Advance directives are often difficult to interpret and apply in the actual circumstances encountered by health care professionals, relatives and proxies.
Advance directives that do not differentiate between proportionate and disproportionate treatments may be promoted by pro-euthanasia associations as a first step toward acceptance of euthanasia.
What is a Provider Orders for Life-Sustaining Treatment (POLST)?

A Provider Orders for Life-Sustaining Treatment (POLST) is a medical order specifying whether life-sustaining treatment is to be used or withheld for a specific patient in various circumstances. It carries the signatures of the health care provider and sometimes the patient.
It differs from a do-not-resuscitate order and a traditional advance directive in that it is actionable from the moment it is signed by the health care provider, even if the patient is still competent and is not terminally ill.

One reason given for use of a POLST and similar instruments is the avoidance of futile or unwanted treatment. Even without a POLST, however, patients are never obligated to submit to health care procedures whose burdens outweigh therapeutic benefits.

Decisions about forgoing life-sustaining treatment should be made at the time and in the circumstances in which the decisions are needed (not years ahead), and they should be made by the patient or the patient’s surrogate in consultation with the patient’s attending physician, in line with the patient’s known wishes and best interest (not by health care workers who are strangers to the patient but have access to his POLST).

The details of a patient’s medical condition at a specific time need to be considered when such decisions are made, including the imminence of anticipated death, the likely risks and side effects of treatment, the suffering treatment is likely to cause, and the expense to the patient’s family and community.

An optimal advance directive is written in very general terms. Instead of specifying treatment, it designates a health care proxy or surrogate who will make decisions if the patient is incompetent, someone who knows the will of the patient and the teachings of the Catholic Church.

What is the difference between an advance directive and a POLST?

An advance directive is a legal document that allows a person to identify a proxy or surrogate decision maker and express his wishes about receiving or forgoing health care, including life-sustaining treatment, in the event that he is no longer able to communicate such wishes. An optimal advance directive is written in general terms that identify principles on which a surrogate is to base decisions, made with the assistance of a physician, in the specific health care situation encountered by the patient.

A POLST is a medical order about receiving or forgoing life-sustaining treatment that takes effect from the moment the health care provider signs it, even if the patient is competent and not terminally ill.

Why is the designation of a health care proxy or surrogate morally preferable to use of a POLST?

Unless death is imminent, it is virtually impossible to compare the benefits and burdens of treatment before a patient has encountered a specific health care situation. Thus, pre-signed checklists of treatments to be received or withheld are not helpful for making decisions based on the best interest of the patient and consistent with the patient’s wishes. A well-informed proxy who knows the patient, understands the values held by the patient, and respects the natural moral law can provide a far better understanding of how the patient’s wishes are to be respected than can a general checklist that is not tied to any specific patient care situation.

Is there a clinical situation in which a POLST could be helpful in directing health care decisions?

When a person is terminally ill and death is anticipated from the underlying disease, and not from the withholding of life-sustaining treatment, it could be helpful to have actionable orders to prevent the initiation of futile or disproportionately burdensome treatment.
— National Catholic Bioethics Center. Learn more online at www.ncbcenter.org.