Saturday, January 27, 2007

When is Euthanasia Not Euthanasia?

Evoking parallels with the Terri Schiavo case in the United States, the Italian Church has been at the center of controversy over the death of Piergiorgio Welby, a man who was paralyzed and kept alive by a ventilator for nine years. The case created a huge political furore, and the Church was painted as a stark opponent of allowing him to die.

First off, this is all incredibly complicated and nuanced. We need to be absolutely clear about what the Church says and what it does not say. For that, I recommend a good article in the Tablet by John Paris S.J., a leading expert on end-of-life issues. First, things first. Euthanasia (or "mercy killing"), like abortion and torture, is evil in its object, which means that no appeal to either intent or circumstance can justify it. As the Catechism says clearly (#22877): "
"Whatever its motives and means, direct euthanasia consists in putting an end to
the lives of handicapped, sick, or dying persons. It is morally unacceptable. Thus an act or omission which, of itself of by intention, causes death in order to eliminate suffering constitutes a murder gravely contrary to the dignity of the human person and to the respect due to the living God, his Creator."
But there is a profound difference between killing somebody and discontinuing treatment that offers no hope of recovery. This distinction is well-grounded in Catholic moral teaching. Again, from the Catechism (#2278):

"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. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected."
The 1980 Declaration on Euthanasia had this to say:

"One cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide [or euthanasia]; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected."
This reflects a very old tradition. As far back in the 4th century, St. Basil wrote: "Whatever requires an undue amount of thought or trouble or involves a large expenditure or effort and causes our whole life to revolve, as it were, around solicitude for the flesh must be avoided by Christians." The distinction between proportionate/ordinary care (which was morally obligatory) and disproportionate/extraordinary treatment (which was not) was worked out in detail by a group of 16th Century moralists, including Domingo BaƱez and Francisco de Vitoria. When Vitoria was asked if a sick person who refused to eat be guilty of suicide, he answered:
"If a patient is so depressed or has lost his appetite so that it is only with the greatest effort that he can eat food, this right away ought to be reckoned as creating a kind of impossibility, and the patient is excused, at least from moral sin, especially if there is little or no hope of life."
In modern times, and in modern medical circumstances, Catholics moralists have arrived at similar conclusions. As noted by Fr. Paris, the eminent Jesuit moralist Gerald Kelly concluded in the 1950s that (in Paris's words): "No one is obliged to use any means - natural or artificial - if it does not offer a reasonable hope of success in overcoming the patient's condition." He stated that this included the use of IV feeding for patients in a terminal coma. Pope Pius XII noted that the use of ventilators was not necessarily obligatory either. And in a recent case, Archbishop Mario Conti of Glasgow, in discussing a case of a woman paralyzed from the neck down, said that:
"The principle here [the request for the withdrawal of a ventilator] is quite different from euthanasia. The request in this case is not for assisted suicide, rather it is for the discontinuation of a medical procedure which is burdensome to the patient."

Paris concludes his essay by appealing to the example set by Pope John Paul II, who refused to go back to the Gemelli Hospital, where he would probably have been hooked up (yet again) to a respirator and feeding tube. Instead he said simply "Let me go to the house of the Father."

The consensus view is elucidated in a thoughtful essay by Brother Daniel Sulmasy, who claims that intervention can be judged extraordinary and disproportionate if it is "too expensive, not likely to work, is associated with great suffering, or might save the patient's life at too great a psychological, spiritual, or interpersonal cost".

In light of this, why did the Church react to Welby in the way they did? Quite simple. Gerald Kelly himself provides an answer when he wrote, in the context of his own position on the licitness of withdrawing IV treatment:
"I frankly hesitate to give a practical answer allowing the physician to discontinue the intravenous feeding as a means to end suffering. I fear the abrupt ceasing of nourishment to a conscious patient might appear to be a sort of ‘Catholic euthanasia' to many who cannot appreciate the fine distinction between omitting an ordinary means and omitting a useless ordinary means."
In other words, these issues can be complicated, and the Church is afraid that its unambiguous treatment on euthanasia would be watered down. It is afraid that nuance will be interpreted as support for suicide and euthanasia. Hence, many in the Church are willing to draw a heavier line than exists in Catholic moral teaching.

This is what happened in Italy. In the Welby case, the patient claimed that the technology was artificially postponing his death and that was too burdensome (he could no longer eat or speak). In many countries, his wishes would have been granted automatically. The issue is that Italian law does not permit the denial of lifesaving care even though the patient can refuse treatment.

The Vatican said clearly that the issue was whether or not the use of the respirator constituted extraordinary measures to postpone his life. But the Church was not willing to take a stance on this question. Accordingly, two top Vatican officials-- Cardinal Javier Lozano Barragan, president of the Pontifical Council for Health Care Ministry, and Bishop Elio Sgreccia, president of the Pontifical Academy for Life-- stated that they did not have enough information to make such a determination. Both Cardinal Barragan and Bishop Sgreccia argued that the doctor should decide. But this is clearly an unsatisfactory position, as the Catechism clearly says that "the decisions should be made by the patient if he is competent and able."

More recently, Cardinal Carlo Maria Martini entered the fray, and appeared more sympathetic to Welby's case, noting that he was fully lucid and that the breathing apparatus offered no possibility of improvement. Although Martini did explicitly condone Welby's decision, he did say that is is generally up to the patient to decide whether the treatment is disproportionate or not. So, at the end of the day, closer to the Catholic tradition, but not that far either from Cardinal Barragan, despite the media playing up in-fighting in the Church over this issue.

So far, so nuanced. But it got a lot worse when Cardinal Camillo Ruini, papal vicar of Rome, refused to grant Welby a Catholic funeral. Although the Diocese of Rome stated clearly that it was being denied because of his long-time advocacy for legalized euthanasia, and not arising from the circumstances of his death, the damage was done. The Church's attempts at nuance were lost. Welby's widow made the valid point that the Church had not refused a Catholic funeral to murderous dictator Pinochet. [As an aside, this gives a glimpse of how the Church's prestige in the US would suffer should they start to deny the Eucharist to pro-abortion politicians.] As Cardinal Martini hinted, “more attentive pastoral consideration" was have been helpful.

So, where do we stand? Paris makes the compelling case that the removing of Welby's respirator was fully consistent with Catholic tradition, at least in terms of similar cases in the past. And yet the Church was loathe to embrace this position, for reasons that are (at least partially) understandable. Still, many people failed to note the nuance in the Church's position and equated Welby's death with text-book euthanasia. The same happened with the Schiavo case, with extremists on both sides contributing to an atmosphere of bitterness than managed to obscure the Church's authentic teaching on the matter at hand.

Going forward, we need far more clarity on end-of-life issues in the modern day. In particular, it would be useful to address these issues:

(1) Is there a difference between refusing to accept treatment, and ending treatment that has already begun? Pope John Paul refused to get back on the ventilator. Welby took himself off. Is there a major ethical difference? Is the latter too close to suicide?

(2) How do advancements in the quality of medical care and treatment affect a tradition that was worked out in context of the 16th Century? Already, as noted in a 2004 papal allocution, the Vatican seems to be saying that artificial nutrition and hydration should now always be seen as ordinary, and thus morally obligatory (which was not the case in the past).

(3) Can we discern an ever-unfolding emphasis in Church teachings on the God-given human dignity of every human being affecting this aspect of Church teaching, as it has many others? In recent times, the Church has restricted its position on the licitness of the death penalty, and sees ever-narrower conditions for the justness of war. Does this general trend have implications for end-of-life issues? Can we argue that the old proportionate-disproportionate distinction places too much weight on "quality of life", in a way that downgrades the human dignity of disabled people?

One thing is for sure: the Church will have a lot more to say about this matter!


Fr Joseph O'Leary said...

typo alert: "Martini did NOT explicitly condone" is what it should be.

Confusion on this issue was generated by some document someone put into the failing JPII's hands that seemed to unsay centuries of Catholic tradition on the matter. Another boon for the fundamentalists.

Morning's Minion said...

Yes, I think it is probable that John Paul did not actually author the 2004 allocution. It seems that his close circle of advisors were focused on the pope's poor health, and realized that he could be soon placed in a situation whereby his life could be prolonged with technologies like feeding tubes and ventilators. In the end, though, the pope embraced death with great dignity.