September 1989 XI/1
MEDICAL ETHICS REQUIRES ACCURATE DISTINCTIONS
Recently, Larry McAfee, a young man in Georgia, quadriplegic and permanently dependent upon a ventilator, wished to remove the ventilator because in his judgment the use of it resulted in more burden than benefit. Because death will result indirectly as a result of removing the ventilator, Larry McAfee and his family were forced to go to court to gain legal approval for the proposed removal. In reporting the decision of Judge Edward Johnson, one newspaper stated: "Judge Gives Quadriplegic Permission to Commit Suicide;" another stated: "Judge Rules Quad Free To End His Own Life." The reporting of this case reminds us of the importance of making accurate distinctions when making an ethical analysis. Indeed, much of the disagreement and misunderstanding in regard to ethical decisions often seems to stem from a lack of clear distinctions. This essay will analyze some ethical terms which often generate confusion because they maybe used with different meanings.
1. Terminal illness: This term may signify that a patient will die in the immediate future even if life support therapy is utilized; for example, a patient with cancer in several vital organs will die soon no matter what therapy is employed. Terminal illness may also indicate the presence of a fatal pathology which will cause death in the immediate future unless therapy or life support is utilized; for example, a person with renal failure has a terminal illness in this sense, but life may be prolonged through dialysis or a kidney transplant. Many believe that a decision to withhold life support may be made only when a terminal illness is present in the first meaning of this term, that is, when the therapy is useless. Catholic teaching allows therapy to be withheld when the second meaning of the term is verified and the therapy would result in a grave burden for the patient. Judge Johnson used this meaning of "terminal illness" in the McAfee Case.
2. Quality of life: This term is sometimes used to signify the physical or mental disability which impairs a person's function, but the disability does not endanger the person's life; for example, a crippled person confined to a bed might be said to have a low quality of life if the term is used with this first meaning. However, the term can also be used to refer to a person whose ability to function is seriously impaired as a result of a serious pathology and whose life is endangered as a result of the pathology; for example, a person who is neurologically impaired because of advanced cancer of the central nervous system.
The confusion arising from the use of this term without proper distinction is monumental. Some state: "Life support should never be withdrawn for 'quality of life' reasons." This is true if the quality of life is used in the first sense. But it is not true if quality of life is used in the second sense. Indeed, even people who denounce quality of life as a criterion for removing the support will admit that life support can be withdrawn if the condition of the patient is hopeless. This is an admission that the "quality of life" in the second sense may be used as a reason for removing life support. In order to avoid the confusion arising from use of this term, Thomas O'Donnell, S.J. introduced the term quality of function and suggests that it be substituted when "quality of life" is used in the second sense. This substitution seems to obviate the confusion arising from the unspecified use of "quality of life."
3. Active and Passive Euthanasia: Through this distinction, people sometimes convey the notion that active euthanasia (inducing a cause of death) is morally wrong, but passive euthanasia (withholding care with the intention of letting a person die) is morally acceptable. But the intention of killing a person either by inducing the cause of death or by being passive and allowing death to occur is ethically unacceptable. Withholding or removing life support from a person is ethically acceptable only if life support will not benefit the patient and the intention of the caregiver is to do something morally good; that is, to cease doing something useless or to avoid inflicting a grave burden upon the patient. As Pius XII pointed out, removing life support with the intention of benefitting the patient even if death is foreseen is an application of the principle of double effect (or indirect voluntary).(1)
4. Ordinary and Extraordinary Means to Prolong Life. this term has a medical and an ethical connotation but people sometimes use the term as though its meaning were self-evident. From a medical perspective, a therapy is ordinary if it is standard or accepted; for example, clearing the air passages of a new born infant is ordinary care, medically speaking. From the medical perspective, a means to prolong life is extraordinary if it is innovative, unusual or unproven; for example, gene splicing to cure thalassemia is extraordinary medical care. From an ethical perspective however, ordinary care signifies medical care which is morally obligatory because it does not impose a grave burden. Extraordinary care is morally optional because its use does involve a grave burden. From a medical perspective a therapy or life support device can be judged ordinary or extraordinary before it is utilized for a particular patient. But from the ethical perspective, the terms may not be applied unless the medical condition of the patient is known. Moreover, from the ethical perspective a therapy or life prolonging mechanism may be judged acceptable by one person with a low quality of function, but maybe judged too burdensome by another person with the same low quality of function. Not every quadriplegic would make the same decision as Larry McAfee because the use of the ventilator would not be judged a grave burden by some.
When analyzing the burden resulting from therapy, some people consider only the physiological effects of the therapy, or consider the therapy as though it had ethical import apart from the person to whom it will be applied. Thus some people hold up a gastrostomy tube and a can of Ensure at national meetings and state: "Installing this tube and administering nutrition through the tube would never be a grave burden because this tube and Ensure are not expensive and tube feeding does not inflict serious pain." But Catholic teaching in regard to grave burden maintains that the burden from therapy may affect the psychological, social, and spiritual functions of the person, as well as the physiological. Moreover, assessing the burden of a therapy apart from the wishes of the person to whom it will be applied is the same as buying a suit without knowing the size or color. Finally, some would confine assessment of burden only to the very act utilizing the therapy. But as John Connery, S.J. pointed out when considering the history of Catholic teaching in regard to grave burden: "In assessing any particular means, it made no difference whether the burden to the patient was experienced before, during or after the treatment." (2)
The analysis of the foregoing terms is not intended to answer any specific ethical questions. However, the potential ambiguity of these terms indicates the need for clarification of terms before specific ethical judgments are offered.
Kevin O'Rourke, OP
1. Pope Pius XII, The Prolongation of Life, (11/24/57)
2. Catholic Mind, 10/80, p.45.
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