End of Life issues

1. End of Life issues Fr James McTavish, FMVD

2. Themes covered • Overview • Euthanasia • Use of painkillers • Ordinary and extraordinary / proportionate and disproportionate means • Artificial nutrition and hydration – the case of Terry Schiavo

3. Importance of formation! Comedian Ali G confusing “Euthanasia” with the “Youth in Asia” http://www.youtube.com/watch?v=Ya_uJHdOtdc&feature=related

4. Etymology of word • Euthanasia • From the greek eu = good thanatos = death • We want a good death! What does it mean?

5. Euthanasia movement

9. “The good Lord gave me a position that obliged me to call what was black, black, and what was white, white” March 1946

10. Cardinal von Galen The Lion of Munster 3 famous homilies in 1941 “Herewe are dealingwithhumanbeings, withourneighbours, brothers and sisters, the poor and invalids . . . unproductive—perhaps! Buthavethey, therefore, lost the right to live? Haveyou or I the right toexistonlybecausewe are ‘productive’? …Onceweadmit the right tokillunproductivepersons . . . then none ofus can besureofhis life. Weshallbe at the mercyofanycommitteethat can put a man on the listofunproductives” (Excerpt from 3rd homily, 3 Aug 1941)

11. Could such things happen today?

12. The Groningen Protocol Euthanasia in Severely Ill Newborns, 2005 Eduard Verhagen, M.D. and Pieter J.J. Sauer, M.D., Ph.D.

13. BBC news July 2009Conductor dies in suicide centre Renowned British conductor Sir Edward Thomas Downes, CBE, has died at the age of 85, after travelling to the assisted suicide centre Dignitas with his wife. He and his 74-year-old wife Joan, who was terminally ill, chose to end their lives at the Swiss centre, their family said in a statement. According to the statement, the couple "died peacefully, and under circumstances of their own choosing".

14. BBC news today German doctor tried for 13 deaths A German doctor has pleaded not guilty to the manslaughter of 13 cancer patients who died from suspected overdoses of pain-killing drugs.

15. Today this proclamation is especially pressing because of the extraordinary increase and gravity of threats to the life of individuals and peoples, especially where life is weak and defenceless. PJP II, Evangelium vitae 3 The need to announce the Gospel of Life in the world of today

16. Definition of Euthanasia “An act or omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated” The Church’s Declaration on Euthanasia, 1980 Euthanasia can be performed by act or omission.

17. ‘Active’ euthanasia Active (direct, positive) euthanasia – When death results from a positive action eg giving a lethal injection to a sick patient. Direct euthanasia consists in putting an end to the lives of handicapped, sick or dying persons. Thus an act or omission which, of itself or by intention, causes death in order to eliminate suffering constitutes a murder gravely contrary to the dignity of the human and person and the respect due to the living god, his Creator. The error of judgment into which one can fall in good faith does not change the nature of this murderous act, which must always be forbidden and excluded. (CCC 2277)

18. ‘Passive’ euthanasia Passive (indirect, negative) euthanasia – Omission of life saving medical care with the intention and result of causing the patients death 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 decision 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. (CCC 2278)

19. Can painkilling drugs be used even if life may be shortened ? Morphine used to relieve pain It will slow down rate of breathing and may shorten life “The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only foreseen and tolerated as inevitable.” (CCC 2279)

20. Overzealous or futile treatment Under treatment How to decide in real life situations if the withholding of treatment is correct or not? We should not under treat but neither should we undertake over-zealous or futile treatment

21. Are there any guiding principles in the Church teaching that can help us?

22. Ordinary & Extraordinary means

23. 16th century …

24. Domingo Bañez OP (1595) Although a man is held to conserve his own life, he is not bound to extraordinary means but to common food and clothing, to common medicines, to a certain common and ordinary pain; not, however, to a certain extraordinary and horrible pain, not to expenses which are extraordinary in proportion to the status of this man. Although that means (amputation) is proportioned according to right reason and from the consequence is licit, it is however, extraordinary.”

25. Ordinary means “Ordinary means of preserving life are all medicines, treatments and operations which offer a reasonable hope of benefit for the patient and which can be obtained and used without excessive expense, pain or other inconvenience.” See Gerard Kelly, “The Duty to Preserve Life”, Theological Studies 12 (1951) 550.

26. Extraordinary means “Extraordinary means of preserving life are those treatments, medicines and operations which are gravely burdensome to the patient, and which cannot be obtained or used without excessive expense, pain or other inconvenience or which, if used, would not offer a reasonable hope of benefit to the patient.”

27. Proportionate meansis any treatment that, in the given circumstances, offers a reasonable hope of benefit and is not too burdensome for the patient or others.

28. Principle of Proportionate and Disproportionate Means • Often used synonymously with the term "ordinary/extraordinary means" since the two sets of terms were equated in the 1980 Vatican Declaration on Euthanasia.

29. DISTINCTIONS • Ordinary = obligatoryOrdinary does not = usual • Extraordinary = optionalExtraordinary does not = unusual

30. As conceived in the Catholic moral tradition, the principle holds that one is obligated to preserve his or her own life by making use of ordinary means, but is under no obligation to use extraordinary means. (see Ethical and Religious Directives, nn. 32, 56 and 57)

31. Ordinary or extraordinary? “It will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources”(See Part IV, Due Proportion in Use of Remedies, The Church’s Declaration on Euthanasia, 1980)

32. Ordinary or extraordinary? Classification is relative to the state of medical progresseg blood transfusions were extraordinary in the 1930’s but now may be an ordinary means of treatment. It is relative to the local medical facilitiesavailable – what is ordinary in the USA eg chemotherapy may be extraordinary in Africa. Financial considerationsmay apply eg weekly kidney dialysis at P7000 per week may be ordinary for one family, but extraordinary for another. How much should the family reasonably do to get the money? Pains and burdens are not the same for each person. The same treatment many offer one patient hope of cure but not another

33. Importance of distinction between ordinary and extraordinary means

34. The case of Terry Schiavo

36. Story • 26 y.o. American woman • Cardiac arrest with anoxic brain damage • Entered PVS • 15 years • Fed with PEG tube

37. Food and water, ordinary or extraordinary treatment?

39. Husband received money • Had another relationship • Wanted to remove tube but parents denied this

41. Pope John Paul II “…the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering.” ADDRESS OF JOHN PAUL II TO THE PARTICIPANTS IN THE INTERNATIONAL CONGRESS ON "LIFE-SUSTAINING TREATMENTS AND VEGETATIVE STATE: SCIENTIFIC ADVANCES AND ETHICAL DILEMMAS" Saturday, 20 March 2004

42. See video clip (from 42 seconds onwards) http://www.youtube.com/watch?v=Z9Ff-JSv6rM

43. The outcome… The American justice system decided to remove her PEG feeding tube and she died of dehydration on March 31, 2005.

44. CDF and AN&H (2007) First question:Is the administrationoffood and water (whetherbynatural or artificialmeans) to a patient in a “vegetative state” morallyobligatoryexceptwhentheycannotbeassimilatedby the patient’s body or cannotbeadministeredto the patientwithoutcausingsignificantphysicaldiscomfort? Response: Yes. The administrationoffood and water evenbyartificialmeansis, in principle, anordinary and proportionatemeansofpreserving life. Itisthereforeobligatoryto the extenttowhich, and foras long as, itisshowntoaccomplishitsproperfinality, whichis the hydration and nourishmentof the patient. In this way suffering and deathbystarvation and dehydration are prevented.

45. CDF and AN&H (2007) • Second question: When nutrition and hydration are being supplied by artificial means to a patient in a “permanent vegetative state”, may they be discontinued when competent physicians judge with moral certainty that the patient will never recover consciousness? • Response: No. A patient in a “permanent vegetative state” is a person with fundamental human dignity and must, therefore, receive ordinary and proportionate care which includes, in principle, the administration of water and food even by artificial means.

46. Concluding…

47. Saint Gregory of Nyssa "Man, as a being, is of no account; he is dust, grass, vanity. But once he is adopted by the God of the universe as a son, he becomes part of the family of that Being, whose excellence and greatness no one can see, hear or understand. What words, thoughts or flight of the spirit can praise the superabundance of this grace? Man surpasses his nature: mortal, he becomes immortal; perishable, he becomes imperishable; fleeting, he becomes eternal; human, he becomes divine". See EV 80 (From De Beatitudinibus, Oratio VII: PG 44, 1280)

48. 2 Timothy 4:2-5 Proclaim the word; be persistent whether it is convenient or inconvenient; convince, reprimand, encourage through all patience and teaching. For the time will come when people will not tolerate sound doctrine but, following their own desires and insatiable curiosity, will accumulate teachers and will stop listening to the truth and will be diverted to myths. But you, be self-possessed in all circumstances; put up with hardship; perform the work of an evangelist; fulfill your ministry.