One day, I received an emergency call from a hospital for a patient who was just admitted to the ICU.  The caller calmly and politely asked for my immediate presence, because the patient was in an extremely critical condition. The family was in deep crisis.

Upon entering the room, I saw Larry (not his real name) who was standing at the bedside of the patient–his wife, Mary (not her real name). Larry told me that they were walking that morning at their favorite park on the beach. It was a gorgeous sunny day with clear light blue skies painting the horizon. The wind was still.

After walking for a couple of miles, Mary started to feel numb and with the onset of a severe headache. She had not experienced this sensation and pain before in her life. She collapsed and became unconscious after a couple of minutes.  Larry called 911, and Mary was immediately brought to the hospital.  After a series of tests, it was revealed that she had a rare case of a brain aneurysm. She was confined to the ICU and was intubated and attached to a mechanical ventilator. She was also hooked up to different types of monitoring devices and was administered IV fluids and feeding tubes.

A comprehensive assessment of Mary’s condition was conducted by two neurologists on staff.  Tests that included CT and MRI scans revealed a severe form of an aneurysm located at the innermost part of the brain. It was inoperable. The doctors confirmed that recovery is no longer possible.  At that time, any treatments would be considered futile (of no benefit or hope for recovery).  Doctors told Larry that they had done their best and had carried out all available procedures to save her life.

That was a distressing development.  No words could describe the sadness felt by the family as they listened to the doctor’s statements.  Larry and his children were not ready to face this tragic reality. They struggled with the uncertainties and dilemmas of what to do and how to proceed with the next step.  Are we going to remove the ventilator?  If so, when? Will we wait for Mary’s heart to stop beating before removing the ventilator and stopping all treatments?

The principle of ordinary and extraordinary means addresses confusion concerning forgoing life-sustaining measures.

The Catholic Church uses the principle of “ordinary and extraordinary measures” to shed light on the moral acceptability of withdrawing or withholding life support and other medical treatments.

The principle of ordinary and extraordinary measures was employed by Catholic Theologians to understand whether a refusal to accept a life-sustaining treatment in certain situations would constitute a failure in the duty to preserve a person’s life. [1] The terms “ordinary and extraordinary means” do not pertain to the level of sophistication of interventions or the technology being used.

The application of this principle is based on the patient’s overall condition and the burdens and benefits involved in the application of a certain medical procedure.

Many people may find the meaning or implication of the terms, ordinary or extraordinary means less clear in categorizing different medical interventions and treatments for a specific medical condition. In the realms of medicine ordinary procedures are those that are scientifically established, statistically successful and reasonably available.

Some medical procedures which used to be considered extraordinary intervention many years ago have now become accepted standard medical protocols, thus becoming ordinary medical interventions.

What is ordinary or extraordinary medical procedure may not be what the words stand as means of conserving life is the theological sense. For example, if a terminally ill patient in a hospice care develops an infection, and it looks like his death is apparent within the next few days, then even a simple course of antibiotic could be considered an extraordinary intervention in the theological sense.

Professor Gary May, a Moral Theologian, makes a distinction between ordinary and ordinary means:

Medical treatment is extraordinary and hence not morally obligatory if objectively discernable features in the treatment itself, and its negative consequences impose grave burdens on the person being treated or on others. Excessive burdensome is the major criterion for determining whether or not to withhold or withdraw medical treatments.

The following  are suggested parameters to determine the  burden of procedures/treatments:

• The riskiness of the treatment (those interventions that offer extremely little reasonable hope of benefit and would involve excessive burden to the patients and families;
• The excessive pain of the treatment and the  severely negative impact that the treatment will have on the subject’s life;
• Treatments that are morally or psychologically repugnant (e.g., a procedure that would cause a severe disfigurement of the body); and
• Treatments that would be too costly and severely imperil the economic security of the patient, the patient’s family, and the community. 

One could forego an excessively burdensome treatment even foreseeing that by doing so one’s life will be shortened, without in any way intending death.[2] Thus, one is called only to pursue ordinary or means of medical intervention—-those that offer a reasonable hope of recovery to patients without excessive expense, pain, or burden.

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.[3]

The well-being of the whole person must be taken into account in deciding about any therapeutic intervention or use of technology.[4] The physician, patient (if able) and family members work closely to determine the illness or pathology, prognosis, benefits, and risks of the proposed treatment, and the financial expense that affects the family and the community at large.

The Church teaching is clear that a person may rightly consider financial costs among the burdens. The person does not need to sacrifice “the financial survival of their families to prolong life, certainly not when the treatment is of questionable benefit and perhaps not even when the treatment is almost surely a cure.”[5] Even a wealthy person who could afford to pursue any expensive treatment or top doctors is be bound to employ this obligation. One need not prolong his/her life with great inconvenience.[6] A person does not need to seek all medical means to treat a serious illness if there is scarce hope for cure and recovery or if the procedure is excessively taxing or if it requires an extremely difficult effort to pursue treatments.

The benefits and the burdens of each treatment/procedure must be assessed for its merit. For instance, a ventilator, which is often used to critically-ill patients may be ordinary when used to a patient who has great chances for recovery.  Ventilators are sometimes indicated for a few days in some cases to allow a patient to recover.  Consider the example of a young, healthy person who ingested a caustic substance who is placed on a ventilator because of breathing difficulty.  A ventilator is placed as a temporary relief until this person can breathe on his own after a certain period.  The ventilator, in this case, is considered as a bridge to recovery. It is like a walker or a cane, which is temporarily used by patients who are not able to walk because of fractures. The ventilator shall be removed when the patient is able to breathe on his own.

There are some interventions that look like simple treatments but categorized as extraordinary means if applied for certain patients. For instance, glucose, given intravenously, which is usually an ordinary intervention given to diabetic patients with an extreme hypoglycemic episode will become extraordinary for a comatose ninety-five-year-old with cardiopulmonary and renal complications. An antibiotic is an ordinary measure to treat infection, but it may become extraordinary for a person who is imminently dying of cancer and other serious conditions.[7]

Another example is an 80-year-old cancer patient who chooses not to pursue a standard treatment procedure because it is lengthy, costly, and painful for his age.  A person with end-stage renal failure chooses to discontinue dialysis because he is bed-bound and lacks the energy to continue treatments and to relate with others.  A person chooses not to pursue a major surgical procedure because the intervention entails financial hardship that would require selling a family’s home or exhausting the funds designated for his children’s education and day-to-day expenses.[8]

Patients or their surrogates do not will or intent to cause death if they chose to forego medical interventions that have little chance of success or are dangerous and painful. The omission allows death to take its natural course, even though death occurs earlier than if aggressive interventions had been carried out.

There are important questions to ask in forgoing burdensome treatments.

Fr. Kevin O’Rourke offers guidance by raising important questions to be used as a tool in determining the removal of burdensome treatments. These questions are: A. Is the fatal pathology present in the body of the patient? B. Does resisting the fatal pathology involve effective or ineffective treatment? C.  If the therapy is effective; does it impose an excessive burden now or in the future; and D. What is the intention of those who decide to remove the life support?[9]

The ultimate question to ask is, does the intention to remove life support and other treatments are to cause death to the patient? If it does, this action would be unethical and morally wrong.  However, when the intention is to remove life support because it is ineffective, unbeneficial and burdensome, then it is to cease doing something futile. Hence, the act is morally permissible. In the latter case, we may remove the life support and other treatments except for those that keep the patient comfortable and free from pain.

The practical difficulties in applying the distinction between ordinary and extraordinary means to prolong life will always remain. Determining whether to allow oneself or a loved one to die will always be a complex and difficult decision to make.

When the removal of life support and other treatments becomes ethically necessary, the death of a loved one usually follows a natural act, an act of God. Death is not desired by those who remove life support in this situation.  Such as refusal is not the equivalent of suicide. Instead, it may simply indicate 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, or a desire not to impose excessive expense on the family or the community.”[10]

We experience inner peace when we carefully follow the ethical ways of decision making. Family members often express relief and healing that death has removed the burden that their loved ones had experienced, not the relief that they are dead.[11]

Resolution to the case of Mary.

Mary’s husband and family agreed to remove her life support after careful conversation with her physician, close family friends, and with me. They realized and accepted the fact that all possible remedies had been exhausted to save Mary. They did their very best to take back her life. They were resigned to discontinue any life-sustaining treatments. However, they asked if they could wait for two more days to give time for Mary’s sister and brother, who lived out-of-state to be with her when the ventilator would be pulled out.

In this case, it is not only acceptable but also compassionate to offer reasonable time and space to the family. This will enable them to emotionally and spiritually prepare for the removal of life support and eventually, for the patient’s death.  This may also help them heal and reconcile past emotional wounds or strained relationships.

Mary’s family was grateful for the precious days they were able to spend time with her and with each other. There was a tremendous sense of peace and healing. It was exactly on the 12^th day of Mary’s confinement when all the expected family members arrived. It also happened to be Mary’s 53^rd birthday.

The family requested me to be with them when the ventilator would be removed.  I arrived in the ICU with the family at the bedside. There was a cake prepared for Mary and they began singing happy birthday soon as I arrived. They also rendered her favorite song.  Each one was given a chance to speak and bid goodbye.  The sadness that echoed in the room was heart-wrenching.

After I said my final commendation and prayer, the husband went out to inform the nurses that they were ready to remove the life-support.  They immediately came and offered comforting words to the family. They administered medication and removed the tube. They continued to monitor Mary for pain and discomfort. Mary’s skin color gradually became pale. Mary’s heartbeat and respiration stopped within a few hours since the life support was removed.

While Mary’s life support was withdrawn when her death was imminent, Dr. David Kelly wrote that “Treatments are morally extraordinary when their burden outweighs benefits, and this does not necessarily require that the treatment itself causes actual harm or that the patient’s death is imminent.” [12]  Dr. Kelly continued, “To claim that treatment can be morally extraordinary only when a person’s death is imminent, regardless of whatever the treatment is given, is to give biological life itself an absolute value that supersedes all other values.”[13]

To sum up, the two major criteria for determining the moral implications of foregoing life support are those of burdensomeness and usefulness. These criteria do not, in any way, imply that the life of sick is either burdensome or useless. Human life, “however heavily burdened and devoid of utilitarian values, is always a great and precious good of irreplaceable persons.”[14]

 

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[1] Grattan T. Brown “Ordinary and Extraordinary Means” in Catholic Healthcare Ethics, A Manual for Practitioners, 16.

[2] William E. May (1990), “Criteria for Withholding or Withdrawing Treatment,” The Linacre Quarterly, 5, No. 9 (August, 1990): 88.

[3] Catechism of the Catholic Church 2^nd ed. (Vatican City: Vatican Press), No. 2278

[4] USCCB, “Ethical and Religious Directives,” No. 33.

[5]  David Kelly, Medical Care at End of Life, 9.

[6] Daniel A Cronin, Ordinary and Extraordinary Means of Conserving Life. National Catholic Bioethics Center: Philadelphia, 2011, 107.

[7] David Kelly, Medical Care at the End of Life, 8.

[8] Catechism of the Catholic Church 2^nd ed., No.100.

[9] Fr. Kevin O’ Rourke, OP, (2000), A Primer for Healthcare Ethics: Essays for a Pluralistic Society, 2^nd ed. (Washington, DC: Georgetown University Press), p 95-102.

[10] Cf Congregation for the Doctrine of Faith, Declaration on Euthanasia, IV AAs 72 (1980), 550-551.

[11] Kevin O Rourke, A Primer for Healthcare Ethics, 101.

[12] David Kelly, Medical Care at the End of Life,103.

[13] David Kelly, Medical Care at the End of Life, 103.

[14] William May, “Criteria for Withholding or Withdrawing Treatment,” 89.