March 1993 XIV/7
ETHICAL CRITERIA FOR REMOVING LIFE SUPPORT
Christine Busalacchi was injured in an automobile accident in 1987. After a series of acute care interventions were unsuccessful, she was diagnosed as being in a persistent vegetative state (p.v.s). Because of the p.v.s. condition, she was unable to eat or swallow. This fatal pathology was circumvented through medically assisted hydration and nutrition. Six years after the accident, when the courts in Missouri finally determined that her medical care should be under the direction of her father, a controversy arose concerning the ethics of removing life support from a person in a persistent vegetative state. Specifically the question of removing artificial hydration and nutrition from Christine was debated on television, in the press, and among health care personnel. Emotion and pietistic assumptions more often than sound ethical reasoning seemed to prompt most statements concerning Christine's care. In an effort to clarify the proper care of persons in p.v.s., this essay will consider the facts and questions that are relevant for an ethical withdrawal of life support.
When considering the use or removal of life support, the first relevant fact concerns the existence of a fatal pathology. A fatal pathology is an illness, disease or bodily condition which will cause the death of a person. Examples of fatal pathologies are diabetes, cancer, or end stage renal disease. If a fatal pathology is present, the question arises: Should attempts be made to remove, circumvent, or alleviate the pathology through medical therap~ Or should nature be allowed to take its course thus allowing the person to die of the existing pathology? Should diabetes be circumvented through the use of insulin, should attempts be made to remove the cancer through surgery, or should attempts be made to alleviate the end stage renal disease through hemodialysis? Usually, people wish to combat fatal pathologies by means of medical therapy. They opt for insulin, surgery, or hemodialysis if their lives are threatened. In most cases, there is an ethical conviction as well as a natural intuition to preserve life through medical therapy because it enables one to strive for the important goods of life. What are these important goods? In general, the important goods are preserving life, seeking the truth, loving our families, generating and nurturing future generations, and forming communities with other people. In particular, each one of us has goods which are important to our sense of purpose and well-being.
In some situations however, extending life through medical therapy does not enable the patient to strive for the goods of life. Or if it does, the therapy imposes a burden which makes striving for the goods of life too difficult. To be more specific, because of the condition of the patient, medical therapy may be either ineffective thus making it impossible for the person to pursue the important goods of life. Or it may impose an excessive burden thus making it too difficult for the person to strive for important goods of life. One situation in which medical therapy usually is ineffective occurs when the patient's death is imminent and unavoidable. Hence, a conscious patient, severely debilitated due to pathologies in many organs, may request removal of a respirator because continued existence in this condition will not allow her to pursue any of the goods of life. Moreover, the same decision to remove life support may be made by family members for a loved one, if the hope of recovering consciousness is slight and death is imminent and unavoidable.
Another condition which renders medical therapy ineffective is the persistent vegetative state (p.v.s.). Because of a dysfunctional cerebral cortex, persons in this condition can never again strive for the goods of life which we identify with human function. Their cognitive-affective function is non-existent and cannot be restored. Thus, they do not have the power to think, love, relate to others, or demonstrate care and compassion nor can these powers ever be regained. In addition, because of damage to the cerebral cortex, persons in p.v.s. are unable to eat, chew, and swallow. This pathology can be circumvented by means of medically assisted hydration and nutrition. But does use of this medical therapy benefit the patient? Does prolonging physiological function, with the realization that the patient will be unable to strive for most of the important goods of life, mandate continued medical intervention? Simply because a person in p.v.s. may be kept alive, does not indicate that the person must be kept alive. Removing life support from persons in p.v.s. is not euthanasia because it neither induces a new cause of death, nor does it imply the intention of killing the patient. (314)577-8195
Medical therapy which imposes an excessive burden for a patient may also be discontinued. An excessive burden may affect a patient's ability to strive for a physiological good, a social good, or a spiritual good which is very important to the patient. The excessive burden under consideration need not be directly associated with the therapy but often results from the use of the therapy. Examples of excessive burden which impede the pursuit of more important human goods occur frequently. A patient with end stage renal disease opts for discontinuing dialysis because he is bedridden and lacks energy to relate to others or care for himself. The father of a family refuses to have surgery because it would involve selling the family home or expending funds designated for education of children. A Jehovah's Witness refuses a life prolonging blood transfusion because she believes receiving blood transfusions is a serious sin.
The question concerning excessive burden is posed after a decision is made that the therapy is effective. Hence, there are two distinct criteria that come into consideration after the existence of a fatal pathology has been medically ascertained: 1) Is the therapy effective? 2) If the therapy is effective, does it impose an excessive burden, whether present or future? Both of these criteria require an evaluation of the patient's ability to strive for the goods of life. In some situations even though medical therapy is utilized, it will not enable the person to strive for the goods of life. Such therapy would be ineffective. In some conditions, medical therapy would enable a person to continue striving for the goods of life, but the therapy would also impose burdens which would make striving for the goods of life very difficult. Such therapy would be an excessive burden. Determining whether therapy is ineffective depends more upon objective evidence than does determining excessive burden. Agreement upon the condition which will lead to imminent and unavoidable death or the inability to regain cognitive-affective function may be reached by reason of objective medical diagnosis. But determining excessive burden is much more subjective. Two people may react differently to the burden of prolonged dialysis treatment. Hence, when people are unable to consent for themselves, it is important to have some idea of how they would evaluate the burden, were they able. Finally, because we are social beings, whether patients decide for themselves or through proxies, evaluation of burden must take into consideration the burden placed upon family and community.
One more question is relevant when considering the removal of life support: What is the intention of the people removing the life support? Clearly, actions which are morally good in themselves may be performed for bad intentions. A person may give money to the poor simply to enhance his reputation. Thus an external act of charity can be perverted by means of the intention. Many people believe that if life support is removed because a is ineffective or because it imposes an excessive burden, that the intention of the family or medical team is to cause the death of the patient. If this were the intention of the people removing life support, it would be unethical. But usually, when removing life support because it is ineffective, the intention of family and medical team is to cease doing something futile. When life support is removed because it imposes an excessive burden, the intention is to remove some form of physiological, social or spiritual burden from the patient. When people remove life support from a loved one because it is ineffective or a serious burden, they often express relief or even joy. Thus, we hear: "Mom has died but she is better off." "Dad's death was a blessing." But what people are expressing through these words is relief and joy that the burden has been removed; not joy and relief that mom or dad is dead. If the ineffective or burdensome therapy could be removed without the ensuing death of mom and dad, then loving children would remove the therapy in a manner which would prolong life. But given the realities of life, when removing life support becomes ethically necessary, the death of the loved one usually follows as an act of nature. It is not desired or intended by the people removing the life support.
Four questions summarize the ethical process which should be followed when removing life support. 1) Is a fatal pathology present in the body of the patient? 2) Does resisting the fatal pathology involve effective or ineffective therapy 3) If the therapy is effective, does the therapy impose an excessive burden? 4) What is the intention of the persons who remove life support?
The ethical process described above is based upon a vision of human life as a quest for goods which fulfill the innate and acquired needs of the person. Human life is a dynamic process of fulfilling interrelated needs through the pursuit of goods. The purpose of medical therapy is to enable a person to fulfill needs by pursuing goods. Often medical therapy accomplishes this goal. But when medical therapy does not enable a person with a fatal pathology to pursue the goods of life, or makes this pursuit too burdensome, then the medical therapy may be withheld or withdrawn, even though death would result.
Kevin O'Rourke, OP
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