The Elephant in the Room

Most of us Americans are blessed with too much health insurance, and we do not use it wisely. The insured demand the most expensive treatment without a thought to how much it costs. We too blithely say, “my insurance will pay for it” without realizing that, in the end, we all pay for it.

The patient has an ethical responsibility to maintain or improve his or her own health as well as control costs. While it would be impossible to implement a program that forces people to live healthy lifestyles, it is reasonable to assume that healthier living would lead to lower healthcare costs.

The United States spends 18 percent of its GDP on healthcare, and the rate of increase far exceeds the rate of inflation. This trend is unsustainable. Healthcare economists estimate that between 40 and 50 percent of annual cost increases can be traced to new technologies or the intensified use of old ones. Economists say the control of technology is the most important factor in bringing costs down.

The problem is that patients expect high tech health care; doctors are primarily trained to use it, medical industries make billions selling it and the media loves to write about it. Technological innovation is as fundamental a feature of American medicine as it is in the industrial sector.

While doctors are often accused of over-prescribing diagnostic tests, this practice may be the result of patients who demand multiple tests - even if some are unnecessary. As health care technology innovates and its use increases, patients with insurance want the newest, most advanced and expensive treatments that insurance will cover. The most expensive treatments are not necessarily the best, and the patient has a duty to participate with the physician in making reasonable and cost-effective choices.

However, there is fierce opposition to any limitation in the use of medical technology; its use is deeply rooted in American culture. And politicians are reluctant to buck public opinion. Under the previous administration, Congress, with the support of physician groups and the health care industry killed two federal agencies designed to assess medical technology from a scientific and economic perspective.

Controlling healthcare costs requires a change in American culture. Since many of the effective means of controlling costs will be painful, due to our love affair with technology, resistance to change will be formidable. Effective control will force patients to give up treatments they think they need, doctors to sacrifice to a considerable extent their ancient tradition of treating patients the way they see fit, and industry to reduce its drive for profit. The fact that European countries can control costs and limit technologies without harming health is a patent rebuke to our way of doing things.

I worry about the Generation Y students in my college classroom. Upon graduation they’ll enter the workforce. Social Security and Medicare payroll deductions and escalating health insurance premiums will shrink their take-home pay each year. Today’s workers are paying the healthcare costs of today’s retired community. Will the money be gone when Generation Y reaches retirement?

Traditional virtues still receive attention in American culture, but discussion of one virtue-thrift-has all but disappeared, as affluence and extravagance have taken center stage. Perhaps we should reflect on the advice of the American Apostle of Thrift - Benjamin Franklin.

Old Ben would view our current healthcare reform discussion as a clarion call to change our ways and embrace the old-time virtue of thrift.  If all new diagnostic tests, procedures and treatments were subject to the rules of evidence-based medicine - objective evidence of superiority as opposed to traditional practice - that would be thrift. If pharmaceutical firms were required to prove the superiority of new and more expensive drugs over older and less costly ones, that would be thrift.  If medical equipment companies, which design new gadgets before the old ones get cold, were required to meet the same test, that would be thrift. If insurance companies were regulated more strictly and less ruled by the bottom line, that would be thrift.

Politicians are reluctant to propose any legislation that would place limits on the consumer. To do so, they fear, would be political suicide. Are they underestimating the virtue of the American people?  The healthcare debate is a “test of the national character. Perhaps the words of Ben Franklin have something to teach us: “Be industrious and frugal, and you will be rich”. If we elephants accept our duties and responsibilities in the healthcare reform process, our thrift will ultimately enrich us with affordable and high-quality healthcare.

Who are the stakeholders in the healthcare system? For the purposes of our discussion we define stakeholders as those entities that are integrally involved in the healthcare system and would be substantially affected by reforms to the system. The major stakeholders in the healthcare system are patients, physicians, employers, insurance companies, pharmaceutical firms and government. Insurance companies sell health coverage plans directly to patients or indirectly through employer or governmental intermediaries. Pharmaceutical firms develop and then market medications which are prescribed by doctors to treat patients. Typically they receive remuneration through insurance or governmental drug-benefit plans. Many employers offer health insurance coverage with varying deductibles and co-pays for their employees. Physicians are the providers of medical care; patients are the recipients. And government subsidizes healthcare for the elderly, the disabled and the poor. All stakeholders have duties and responsibilities.

Clearly the interrelationship among the stakeholders in the healthcare system is rather complex. Two of the stakeholders, pharmaceutical firms and insurance companies, are publically owned corporations listed on the stock exchange. Their primary responsibility is to maximize stockholder wealth. Likewise, the primary goal of employers is to make money; however, their provision of health insurance for employees is a benefit, not a source of profit. Unlike the other stakeholders physicians have direct fiduciary duties and responsibilities towards their patients. Although they receive remuneration for their services, the doctor-patient relationship is a sacred trust that transcends monetary reward. Patients have rights, duties and responsibilities. Finally, democratic government has duties and responsibilities towards its citizens, but how they are defined in regard to the provision of healthcare is an evolving American story.

Insurance Industry

Currently rising premiums and strict requirements are keeping many people from obtaining health insurance. The insurance companies remain profit driven, but the nature of their service should not be profit focused. Adequate healthcare is becoming harder to obtain due to financial hardship. The insurance companies need to find an appropriate balance between their responsibilities towards both shareholders and patients. Quarterly reports for stockholders encourage the companies to focus more on profits than affordability. This causes insurance companies to have tight regulations against preexisting conditions so that mostly healthy individuals are selected for their plans. Such patients will not utilize costly procedures as often as individuals with chronic illnesses. However, this is unethical of insurance companies because it reduces healthcare to a profit centered industry, and prevents those in need from receiving care.

Pharmaceutical Companies

Pharmaceutical companies also play a key role in the healthcare system because many patients rely on their products. The prices for drugs are rising, and there are no caps to prevent them from reaching extravagant prices. The argument that the pharmaceutical companies need to charge ever higher prices to cover research costs is simply not true. Although PHARMA spent $43 billion on R&D in 2006, it spent nearly twice as much on promotion, and it consistently has profit margins far above those of most Fortune 500 companies.

Whether or not you argue that pharmaceutical companies have a moral responsibility to ensure that people can afford their products, at the very least they have the duty to be honest and practice fair marketing. Marcia Angell, previously an editor of the New England Journal of Medicine, has written extensively about the unethical behaviors of pharmaceutical companies. Let me cite one example. Through personal experience the author who had an office practice since the early 1980s, witnessed a sinister change in the way pharmaceutical companies market their products to physicians. Previously they sent pharmacists with depth of knowledge about their products to objectively educate the physician about the benefits and risks of a particular brand medication. However, since the late 1980s pharmaceutical firms send young attractive representatives with no formal training to market their drugs by establishing a social relationship with the physician and by offering incentives to prescribe their product. Many physicians whose prescribing practices are unduly influenced by pharmaceutical representatives share the blame. They tend to respond to conversation about certain drugs rather than reading the biomedical literature. 

Physicians

Physicians play a key role in ensuring that their patients receive adequate healthcare, but also in controlling the rising costs of healthcare. They have to find a balance between having a gatekeeper role for the insurance companies and being an advocate for the patient. Assigning a gatekeeper role to primary care physicians had the intention of lowering healthcare costs because fewer tests and referrals would be made. However, this is not working and it may be best to re-evaluate the role a primary care physician has in regards to referring patients. A coordinator role may be more beneficial than gatekeeper status. Also, since primary care physicians have increased the number of patients seen in a day to compensate for their decrease in revenue, this causes an increase in defensive diagnostic testing. The doctors do not have adequate time to review the chart or spend time with the patient, so they order more tests to reduce their liability risks. These actions cause healthcare spending to increase as well. By placing the physician between these two roles, a conflict of interest is created. Ethically, the doctor has a fiduciary duty to protect the interests of his patient, but in the current managed care environment, insurance companies give incentives to physicians to order fewer referrals and to cram more patients into each workday. Edmund Pellegrino stated, “What our health policies do to the individual patient serves as a reality check to what values we hold most dear and the ethical foundation of the policies we develop and impose”. It appears that money is at the center of our values.

 

Physicians also have obligations to patients independent of insurance companies. A physician has an obligation of beneficence to do whatever is necessary to benefit his patient. However if he acts independently (”doctor knows best”) without taking into account the desires of his patient, he is practicing paternalism. Thus, the obligation of beneficence must be balanced by the principle of patient autonomy. Each patient is unique and has the right to participate completely in decisions about his health.

 

Patients

Patients also have an ethical responsibility towards their own health and towards controlling costs. While it would be impossible to implement a program that forced people to live healthy lifestyles, it is reasonable to assume that healthier living would lead to lower healthcare costs. Some companies, such as Wal-Mart and the WHO, have stopped hiring employees that smoke to reduce healthcare related costs. Often doctors are accused of over prescribing diagnostic tests, but this practice may be the result of patients who demand multiple tests even if some are unnecessary. As technology increases patients with insurance want the newest, most advanced, and expensive treatments that their insurance plan will cover, and oftentimes physicians succumb to their requests. The most expensive treatments are not necessarily the best, and the patient has a duty to participate with the physician in making reasonable and cost-effective choices.

Government

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable rights that among these are Life, Liberty and the pursuit of Happiness”. The Declaration of Independence seems to juxtapose two rights: the right to equality and the right to liberty. Equalitarians emphasize the former; libertarians, the latter. Equalitarians hold that healthcare is a human right; libertarians hold that healthcare is a commodity. Equalitarianism emphasizes the role of government and is more appealing to democrats; libertarianism emphasizes the role of free market and is more appealing to republicans. The fundamental chiasm between these two contrasting ideologies which are operative in American culture remains an impediment to healthcare reform in the United States.

 

 

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PHARMA Press Release (Feb 12, 2007) http://www.phrma.org/news_room/press_releases/r&d_spending_by_u.s._biopharmaceutical_companies_reaches_a_record_$55.2_billion_in_2006/

Gargon M, Lexchin J. The Cost of Pushing Pills: A New Estimate of Pharmaceutical Promotion Expenditures in the United States, PLoS Med 2008 5(1) http://www.dddmag.com/news-marketing-expenses-twice-research-investment.aspx

Angell M.

 

The Truth About the Drug Companies: How They Deceive Us and What to Do About It, NY: Random House, 1985Prosser H, Soloman A, Walley T. Influences on GP’s Decisions to Prescribe New Drugs-The Importance of Who Says What. Family Practice 2003 Feb 20 (1):61-8.

Bodenheimer T, Bernard L, Casalino L. Primary Care Physicians Should Be Coordinators, Not Gatekeepers, JAMA 1999 June 2; (281):2045-2049.

DeKay ML, Asch DA. Is the Defensive Use of Diagnostic Tests Good for Patients, or Bad? Medical Decision Making 1998 (18):19-28.

Marcinko, D. The Business of Medical Practice: Advanced Profit Maximization Techniques for Savvy Doctors. Springer, 2004.

 

 

Rodriguez-Osorio CA, Dominguez-Cherit G. Medical decision making: paternalism versus patient centered (autonomous) care. Current Opinions in Critical Care 2008 Dec; 14(6):708-13.Steinbrook R. Imposing Personal Responsibility for Health New England Journal of Medicine 2006 Aug 24; (355):653-756.

　

　

 

 

　

General Christian View

Christians are mostly against euthanasia. The arguments are usually based on the beliefs that life is given by God and that human beings are made in the image of God.

Life is a gift from God.  All life is God-given. Birth and death are part of the life processes which God has created, so we should respect them. Therefore no human being has the authority to take the life of any innocent person, even if that person wants to die 

Human beings are valuable because they are made in God’s image.  Human life possesses an intrinsic dignity and value because it is created by God in his own image for the distinctive destiny of sharing in God’s own life. Saying that God created humankind in his own image doesn’t mean that people actually look like God, but that people have a unique capacity for rational existence that enables them to see what is good and to want what is good. As people develop these abilities they live a life that is as close as possible to God’s life of love. This is a good thing, and life should be preserved so that people can go on doing this.

To propose euthanasia for an individual is to judge that the current life of that individual is not worthwhile. Such a judgement is incompatible with recognising the worth and dignity of the person to be killed.  Therefore arguments based on the quality of life are completely irrelevant. Nor should anyone ask for euthanasia for themselves because no-one has the right to value anyone, even themselves, as worthless.

Position of Catholic Church

Nothing and no one can in any way permit the killing of an innocent human being, whether a fetus or an embryo, an infant or an adult, an old person, or one suffering from an incurable disease, or a person who is dying. Furthermore, no one is permitted to ask for this act of killing, either for himself or herself or for another person entrusted to his or her care, nor can he or she consent to it, either explicitly or implicitly, nor can any authority legitimately recommend or permit such an action. For it is a question of the violation of the divine law, an offense against the dignity of the human person, a crime against life, and an attack on humanity.

It may happen that, by reason of prolonged and barely tolerable pain, for deeply personal or other reasons, people may be led to believe that they can legitimately ask for death or obtain it for others. Although in these cases the guilt of the individual may be reduced or completely absent, nevertheless the error of judgment into which the conscience falls, perhaps in good faith, does not change the nature of this act of killing, which will always be in itself something to be rejected. The pleas of gravely ill people who sometimes ask for death are not to be understood as implying a true desire for euthanasia; in fact, it is almost always a case of an anguished plea for help and love. What a sick person needs, besides medical care, is love, the human and supernatural warmth with which the sick person can and ought to be surrounded by all those close to him or her, parents and children, doctors and nurses.

Position of Protestant Denominations

A number of Protestant denominations have issued statements on euthanasia and physician assisted suicide. Conservative faith groups tend to be most vocal in their opposition. Liberal denominations tend to be more in favor of individual choice.

Anglican: Rowan Williams, the Anglican Archbishop of Canterbury, has stated that although ‘There is a very strong compassionate case’ for physician-assisted dying, the Anglican Church remains opposed to the practice.Some Episcopalians believe it is morally wrong to take human life with medication to relieve suffering caused by incurable illness. Others approve of assisted dying in rare cases.

Episcopal:

Lutheran: As a church we affirm that deliberately destroying life created in the image of God is contrary to our Christian conscience. While this affirmation is clear, we also recognize that responsible health care professionals struggle to choose the lesser evil in ambiguous borderline situations — for example, when pain becomes so unmanageable that life is indistinguishable from torture.

Baptist: Assisted dying violates the sanctity of human life.

Methodist: Methodists generally accept the individual’s freedom of conscience to determine the means and timing of death. Some regional conferences have endorsed the legalization of physician assisted dying.‘Euthanasia’ or ‘mercy-killing’ of a patient by a physician or by anyone else, including the patient himself (suicide) is murder.

Presbyterian Church in America:

United Church of Christ: The Church affirms individual freedom and responsibility. It has not asserted that hastened dying is the Christian position, but the right to choose is a legitimate Christian decision.Pro-choice statements have been made by the United Church of Christ, and the Methodist Church on the US West coast. The Episcopalian, Methodist, and Presbyterian are amongst the most liberal, allowing at least individual decision making in cases of active euthanasia.

Mainline and Liberal Christian denominations:

Position of Judaism

Euthanasia, physician-assisted suicide, and all other types of suicide are almost unanimously condemned in Jewish thought, primarily because it is viewed as taking something (a human life) that belongs to God for “only He who gives life may take it away.” For Judaism, human life is, “created in the image of God.” Although life is considered to be God’s creation and good, human life is related to God in a special way: it is sacred. The sanctity of human life prescribes that, in any situation short of self-defense or martyrdom, human life must be treated as an end in itself. It may thus not be terminated or shortened because of considerations of the patient’s convenience or usefulness, or even sympathy with the suffering of the patient. Thus euthanasia may not be performed either in the interest of the patient or of anyone else.

Jewish law strongly condemns any act that shortens life and treats the killing of a person whom the doctors say will die in any event to be an act of murder. Positive euthanasia is thus ruled out. Even individual autonomy is secondary to the sanctity of human.

Position of Islam

Human life per se is a value to be respected unconditionally. The concept of a life not worth living does not exist in Islam. Justification of taking life to escape suffering is not acceptable in Islam. The Prophet Mohammad said: “Among the nations before you there was a man who got a wound and growing impatient with its pain, he took a knife and cut his hand with it and the blood did not stop until he died. Allah said, ‘My slave hurried to bring death upon himself so I have forbidden him to enter Paradise’” (Qur’an 4:29).

During one of the military campaigns one of the Muslims was killed and the companions of the prophet kept praising his gallantry and efficiency in fighting, but, to their surprise, the Prophet commented, “His lot is hell.” Upon inquiry, the companions found out that the man had been seriously injured so he supported the handle of his sword on the ground and plunged his chest onto its tip, committing suicide.

Patience and endurance are highly regarded and highly rewarded values in Islam. “Those who patiently persevere will truly receive a reward without measure” (Qur’an 39:10). “And bear in patience whatever ill maybe fall you: this, behold, is something to set one’s heart upon” (Qur’an 31:17). When means of preventing or alleviating pain fall short, this spiritual dimension can be very effectively called upon to support the patient who believes that accepting and standing unavoidable pain will be to his/her credit in the hereafter, the real and enduring life.

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[1]  “Declaration on Euthanasia”, The Sacred Congregation for the Doctrine of the Faith, May 5, 1980 http://www.usccb.org/prolife/tdocs/euthanasia.shtml (accessed March 14, 2011)

 [1]  “Religion and Spirituality” The Death with Dignity National Center (DDNC), Oct. 13, 2009 http://euthanasia.procon.org/view.answers.php?questionID=000154 (accessed March 14, 2011)

Physician-Assisted Suicide generally refers to a practice in which the physician gives a patient a prescription for a lethal dose of medication, which the patient intends to use to end his/her life. The physician provides the means for death but it is the patient who must make the conscious decision to use the drug to effect death. For those who take the drug, the physician’s writing a prescription is a necessary step in the process that leads to the patient’s death, but it is not the determinative or even the final step.

 

Euthanasia, on the other hand, generally means that the physician acts directly, for instance by giving a lethal injection, to end a patient’s life. The physician, at the patient’s request, not only provides the means for death but also is the agent of death.

 

 

Why Do Patients Request Physician-Assisted Suicide?

 

•         Severe physical and emotional suffering

•         Not wanting to live in pain

•         Not wanting to be a burden

•         Not wanting to be dependent on others for personal care

•         Depression

•         Hopelessness

•         Being tired of life

•         Loss of ability to maintain personal relationships

•         Problems in interpersonal relationships

•         Feelings of isolation and separation

•         Financial pressures

 

Some studies suggest that issues of dignity, control and independence motivate requests for PAS more often than unrelieved pain or other symptoms. Patients want to be in control by having a lethal dose of medication on hand in case suffering should become intolerable in the future.

 

Is Physician Assisted Suicide Legal?

As of January 2011, physician-assisted suicide is legal in 3 states (Oregon, Washington and Montana). Other states are considering PAS legislation. The Oregon Death with Dignity Act typically serves as a template for the other states.

To request a prescription for lethal medications, the Oregon Death with Dignity Act requires that a patient must be:

 

·        An adult (18 years of age or older).

·        A resident of Oregon.

·        Capable (defined as able to make and communicate health care decisions), and

·        Diagnosed with a terminal illness that will lead to death within six months.

 

To receive a prescription for lethal medication, according to the Oregon Death with Dignity Act, the following steps must be fulfilled:

 

·        Two oral requests to physician, separated by at least 15 days.

·        Written request, signed in the presence of two witnesses.

·        Confirmation of diagnosis & prognosis by a consulting physician.

·        Confirmation of competency by both prescribing and consulting physician.

·        If either physician believes the patient’s judgment is impaired by a psychiatric or psychological disorder, the patient must be referred for a psychological examination.

·        The prescribing physician must inform the patient of feasible alternatives to assisted suicide, including comfort care, hospice care, and pain control.

·        The prescribing physician must request, but may not require, the patient to notify his or her next-of-kin of the prescription request.

 

 

Is Physician-Assisted Suicide Ethical?

 

Arguments against Physician-Assisted Suicide

1.      Sanctity of Life: Physician-assisted suicide is morally wrong because it contradicts strong religious and secular traditions against taking human life.

 

2.      Passive vs. Active Distinction: There is an important moral difference between passively “letting die” and actively “killing.” Treatment refusal or withholding treatment equates to letting die (passive) and is justifiable, whereas physician-assisted suicide equates to killing (active) and is not justifiable.

 

3.      Potential for Abuse: Here the argument is that certain groups of people, lacking access to care and support, may be pushed into assisted death. Furthermore, assisted death may become a cost-containment strategy. Burdened family members and health care providers may encourage option of assisted death. To protect against these abuses, it is argued, physician-assisted suicide should remain illegal.

 

4.      Integrity of the Medical Profession: The Hippocratic Oath states, “I will not administer poison to anyone where asked,” and “Be of benefit, or at least do no harm.” Furthermore, major professional groups (AMA, AGS) oppose assisted death. The overall concern is that linking physician-assisted suicide to the practice of medicine could harm the public’s image of the profession.

 

5.      Physicians Make Mistakes: These may include:  errors in diagnosis and prognosis, failure to diagnosis depression, inadequate treatment of pain, etc. Since these types of mistakes may result in unnecessary death, the State has an obligation to protect human lives from these inevitable mistakes.

 

 

Arguments in support of Physician-Assisted Suicide

 

·        Respect for Autonomy: Death with Dignity legislation fulfills the 4 criteria for making autonomous choices: knowledge of the intended procedure, ability to weigh various alternatives, mental competence and lack of coercion. Decisions about time and circumstances of death are very personal. Competent person should have right to choose death.

 

·        Justice: Justice requires that we “treat like cases alike.” Competent, terminally ill patients are allowed to hasten death by refusal of burdensome life-sustaining treatments. For some patients, treatment refusal will not suffice to hasten death; their only option is suicide. Justice requires that we should allow assisted death for such patients.

 

·        Compassion: Some physical and psychological burdens are so severe they cause unbearable suffering that goes beyond pain. It is not always possible to relieve this kind of suffering. Thus physician-assisted suicide may be a compassionate response to unbearable suffering.

 

·        Individual liberty vs. state interest: Though society has strong interest in preserving life, that interest lessens when person is terminally ill and has strong desire to end life. A complete prohibition on assisted death excessively limits personal liberty. Therefore physician-assisted suicide should be allowed in certain cases.

 

·        Openness of discussion: Some would argue that assisted death already occurs, albeit in secret. For example, morphine drips ostensibly used for pain relief may be a covert form of assisted death or euthanasia. That physician-assisted suicide is illegal prevents open discussion, in which patients and physicians could engage. Legalization would promote open discussion.

 

 

The Following Conditions May Justify Physician-Assisted Suicide

 

•         Voluntary request by competent patient

 

•         Ongoing patient-physician relationship

 

•         Mutual and informed decision making by patient and physician

 

•         Supportive yet critical and probing environment of decision making

 

•         Considered rejection of alternatives

 

•         Structured consultation with other parties in medicine

 

•         Patient’s expression of a durable preference for death

 

•         Unacceptable suffering by the patient

 

Use of a means that is as painless and comfortable as possible

Q & A Regarding the Revision of Directive #58 in the  Ethical and Religious Directives for Catholic Health Care Services

Why did the bishops revise Directive #58 now?

The United States Conference of Catholic Bishops had extensively rewritten the Ethical and Religious Directives for Catholic Health Care Services (ERDs) in 1994 and last revised the document in 2001.  At that time, the Holy See had not spoken regarding the morality of providing medically assisted nutrition and hydration (MANH) to patients in a persistent vegetative state (PVS).  The Introduction to Part Five of the ERDs at that time explained that there was a “necessary distinction between questions already resolved by the magisterium and those requiring further reflection, as for example, the morality of withdrawing MANH from a person who is in the condition that is recognized by physicians as the ‘persistent vegetative state.’”  However, in March 2004, Pope John Paul II addressed this issue and in August 2007, the Congregation for the Doctrine of the Faith issued a clarifying document on the issue. Therefore, the Introduction to Part Five and Directive #58 have been revised in light of these statements.

Does Directive #58 now require that all patients who cannot take food and fluids by mouth receive MANH?

No, it does not. What the revised Directive does say is that patients who both can be fed and hydrated and who would benefit from being provided with food and water, even by artificial means, should, as a general rule, be fed and hydrated. In other words, there is a general moral obligation to provide patients with nutrition and hydration.

This general obligation applies as well to patients who are in a chronic condition and who could continue to live if they are provided with nutrition and hydration. This part of the Directive focuses particularly on patients in a persistent vegetative state and embodies the teaching of Pope John Paul II contained in his 2004 address as well as the statement made by the Congregation for the Doctrine of the Faith in September 2007.

However, the Directive also notes that there are exceptions to this general obligation:

• With regard to dying patients, nutrition and hydration may be deemed excessively burdensome to the patient or may provide little or no benefit in which case they become morally optional.

• With regard to patients in a chronic condition, for example, a patient in a persistent vegetative state, the obligation could also become morally optional if providing nutrition and hydration cannot be expected to prolong life or become excessively burdensome or cause significant physical discomfort (e.g., medical complications resulting from the use of medically administered nutrition and hydration).

So while the Directive emphasizes the general moral obligation to provide nutrition and hydration, even when administered medically, it also recognizes that this obligation is not absolute and that the use of these measures must be assessed with regard to their benefits and burdens to the patient.

Must all patients in a persistent vegetative state (PVS) receive MANH?

The revised Directive #58 makes two assertions in this regard:  (1) that in principle there is an obligation to provide food and water to patients, and that this includes MANH for those who cannot take food and water orally and (2) that MANH becomes “morally optional” when (a) they can no longer prolong life or (b) when they become “excessively burdensome for the patient.”  This judgment is a clinical judgment between the patient (or surrogate) and the physician.  Among the clinical elements that need to be assessed are: the indications and contraindications of tube feeding for this particular patient and understanding potential medical complications that might occur. In the actual circumstances facing a given patient, MANH might not be appropriate. The Directive insists, however, that it must be the MANH that is considered burdensome and not the PVS condition itself. The belief that a patient is never likely to regain consciousness is not in itself a sufficient reason for withdrawing MANH.

Will Directive #58 significantly increase the number of people receiving MANH?

Although at this point in time, the answer to this question is rather speculative, it is not likely that Directive #58 will significantly increase the number of people on MANH.  The Directive merely puts into the ERDs a teaching that has been in effect for several years.  There is no indication of a significant increase in MANH for PVS patients in either 2004 or 2007.

Will a Catholic hospital initiate MANH against the patient’s wishes?

No hospital or physician, including a Catholic hospital or physician, may ever initiate a non-emergency invasive procedure, such as inserting percutaneous endoscopic gastrostomy (PEG) tube, without the permission of the patient or his or her surrogate. This could be considered an affront to human dignity and, in addition, could give rise to legal proceedings.

Does the new Directive #58 mean that Catholic health care facilities will not honor a patient’s advance directive?

No, it does not. In the vast majority of cases, patients’ advance directives will be honored. As previously noted, MANH at the end of life may be medically inappropriate. There may be the occasional situation, such as some patients in a persistent vegetative state, when what the patient is requesting through his or her advance directive is not consistent with the moral teaching of the Church. In these few cases, the Catholic health care facility would not be able to comply.

But this is nothing new. Directives #28 already notes that “the free and informed health care decision of the person or the person’s surrogate is to be followed so long as it does not contradict Catholic principles.” And Directive #59 echoes this: “The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life-sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching.” In those rare instances when the Catholic health care organization is not able to comply with an advance directive, it is not permitted to impose MANH upon the patient contrary to the patient’s wishes as they are expressed in the advance directive or by the patient’s surrogate. This could give rise to legal proceedings. Instead, other options would need to be explored.

Does Directive #58 place Catholic health care facilities in conflict with Federal and/or state laws?

Directive #58 does not appear in and of itself to conflict with any federal or state law.  Whether the application of Directive #58 will conflict with a given state law depends on the circumstances of each individual case.

Does the revision of Directive #58 change the standard of care, often described as ordinary and extraordinary means, as traditionally used by Catholics?

Part of the long moral tradition of the Catholic Church regarding end of life issues has been the moral distinction between “ordinary” and “extraordinary” means.  As shown in Directives #56 and #57, this distinction involves an assessment of the burdens and benefits of a treatment.  Those means of preserving life are proportionate or “ordinary” and therefore obligatory when “in the judgment of the patient [they] offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community” (Directive #56).  Those means of preserving life are disproportionate or “extraordinary” and therefore nor morally obligatory when “in the judgment of the patient [they] do not offer a reasonable hope of benefit or entail an excessive burden or impose excessive expense on the family or the community” (Directive #57). The language of Directive #58 continues to allow for this burden/benefit assessment with regard to MANH.  However, by means of the Directive, the Catholic bishops also maintain that it must be the MANH, which is considered excessively burdensome, and not the PVS condition itself.

Please note: This document reflects the views of CHA ethics staff and is not intended to be an official interpretation of Directive #58.