There is a significant amount of confusion in present society surrounding the issues of death and dying. Many of our colleagues and peers in the medical environment make no distinction between euthanasia (active killing) and withdrawal of burdensome support from a dying patient. This confusion is exacerbated by articles in the lay press. One recent editorial advocated "allowing" Terri Schiavo "to die" by removing her feeding tube. In fact, Terri, a young woman in a persistent vegetative state, is not dying; removing her feeding tube would be killing her.
Conversely, another recent article advocated using "leftover" frozen embryos from fertility clinics to create stem cell lines, arguing that they "were going to be killed anyway." The obvious ethical problem with how these embryos were created is not the topic of this article, but once created, they are human beings who deserve to be treated with respect rather than be killed for our own ends.1 In fact, the Church tells us that all those "whose lives are diminished or weakened deserve special respect."2 To remove these embryos from the freezer is to allow them to die a natural death; to "harvest" cells from them in order to create a stem cell line is to kill them. The confusion often seen between "allowing to die a natural death" and "actively killing" contributes to the public misunderstanding of the underlying medical and ethical issues. It is important to clarify the difference between killing and permitting death, in order to understand and to be able to explain the Church's teachings on a wide variety of issues related to medical ethics.
A Hypothetical Case History
A hypothetical case history can be used to illustrate this. A newborn baby boy was noted in the nursery to be dusky (bluish) after being fed. He did not improve with oxygen, and the pediatrician suspected congenital heart disease. A cardiology consultation was obtained, and the cardiologist identified hypoplastic left heart syndrome (HLHS; severely defective development of the left side of the heart). Surgical palliation of HLHS is complicated and high-risk. It requires three operations during the first several years of life. The first operation, done in the neonatal period, carries a reported mortality range of 10_50 percent in most studies.3 The baby's parents, who were Catholic, were told that their child had a severe heart defect, and that he would need surgery to survive. He was transferred to a nearby children's hospital, where he was stabilized and taken to surgery a few days later. This infant, although a good candidate for surgery, did not do well in the operating room. In fact, after the repair was completed, the heart function was poor and the baby could not be weaned from the heart-lung machine. He was taken to the pediatric intensive care unit on a small, portable pump. Sometimes the heart recovers with time, but the chances of recovery are miniscule if there is no recovery within a few days. The baby was maintained in the intensive care unit on the heart-lung machine, the ventilator, and high doses of medications to keep his blood pressure relatively normal. After six days, there was still no recovery.
At this point, a meeting was held to discuss the options for management. It was attended by representatives of each group participating in the baby's care: the surgeon who operated on the baby, the cardiologist, the neonatologist, the pediatric intensive care specialist, and several nurses. Everyone agreed that the baby could not survive, and that he should be taken off the heart-lung machine. This information was presented to the parents: they were told that the heart-lung machine is extraordinary support that cannot be continued indefinitely. It was unlikely that the baby would survive being taken off the machine. The parents understood and agreed. The baby was baptized.
Several hours later, the parents were ready. The physician at the baby's bedside gave him a large dose of morphine, followed by a large dose of pancuronium (a muscle relaxant which paralyzes all the musclesâ€”thus preventing him from trying to breathe). He then turned off the ventilator, removed the breathing tube, stopped all the medications that were helping keep the blood pressure normal, and, last, turned off the heart-lung machine. The baby rapidly died. His father was at his bedside.
What's Wrong with This?
Obviously, there is something wrong with this picture. Many health care professionals would argue that this child was dying anywayâ€”and that it was better to be quick, better to not have the parents see the child gasp, better to cause as little suffering as possible to everyone involved. After all, the end point is the same, they say: the baby is dead.
"Thou shalt not kill." Killing another person is prohibited by the natural law, by the scriptures, and by the Church. A physician cannot give a patient a drug that is intended to hasten death, no matter what the circumstances.4 A moral evil cannot be converted to a good by the best of intentions; we cannot intentionally cause or hasten death even in a patient who has an incurable disease or who is dying.5
In the intensive care unit today, it is often difficult to tell a patient or their family members that we have "done everything," or that we cannot think of anything else that can be done. The Church teaches us, however, that we are not bound to do everything that can be done to forestall death.6 In some cases, difficult or burdensome treatments can be legitimately withheld or discontinued in a patient who is dying. The decision to withhold or discontinue a given treatment from a specific patient depends on its cost/benefit ratio. Treatments that are painful or risky are more often appropriately declined than are those that are considered routine, but even relatively simple treatments (like nutrition and hydration) can be withheld in selected circumstances if they are thought to be of no benefit. The final phrase is the key, because "the ordinary care owed to a sick person cannot be legitimately interrupted."7
This may be true, for example, when death is imminent (expected within hours or a few days) and nutrition is difficult to provide, or when the patient's medical condition makes it not possible for him to absorb or utilize nutrients. Similarly, drugs can be given to treat the patient (for example, to control pain), even if there may be a side effect that could be life threatening.8 Life-sustaining treatments such as medications, ventilators, and mechanical circulatory support can be discontinued when a patient is dying, but always with the intention not of killing but of diminishing suffering. "To forego extraordinary or disproportionate means is not the equivalent of suicide or euthanasia; it rather expresses acceptance of the human condition in the face of death."9This may at first seem like a matter of semantics, but it is not. Support is withdrawn always while holding onto the glimmer of hope that the patient may, after all, pull through. Medications (such as appropriate doses of narcotics to control pain) can and generally should be given, but overdoses must be avoided and drugs (such as, in the case of the baby described above, muscle relaxants) that are in no way therapeutic for the patient and are directly intended to hasten death should never be given.
A Critical Difference
In the case illustrated above, an infant was dying and the caregivers at the bedside attempted to minimize the suffering of the infant, the parents, and their colleagues. Unfortunately, their well-intentioned attempts were misguided, because they failed to appropriately distinguish between permitting death and killing. The group consensus had been to withdraw the heart-lung machine only, which in this situation is clearly appropriate. Discontinuing the ventilator support, given the anticipated outcome, is also morally permissible, although it should have been discussed with the other caregivers and with the parents in advance, so that they could participate in the decision. Discontinuing the medications that are supporting the blood pressure is more problematic, since their administration in this setting does not add any additional discomfort to the patient. However, continuing high doses of drugs to stimulate the heart may merely prolong the inevitable, so it is not unreasonable to stop them in certain situations, including in this case. The use of pain medications (morphine) and sedatives is appropriate, but they should be given only in therapeutic doses, tailored to reduce pain and anxiety; this infant was intentionally given a high enough dose of morphine to cause respiratory depression, a lethal side effect, which is obviously inappropriate. Finally, the use of pancuronium for the purpose of preventing the baby from breathing is an act of direct euthanasia (direct killing), which is always wrong.
It is of paramount importance that we distinguish in our own practice, and help our colleagues to make a distinction, between killing and permitting death. The focus must always be on the patient. First, we can ask the question: is this person dying? If the answer is "no," then all medical care which is likely to be of benefit should be continued. When the person is dying, treatments that are unlikely to be of benefit, and those in which the cost (in any sense, but usually in terms of suffering for the patient) is disproportionate to the benefit, can be declined. In no case can treatment be discontinued with the intention of hastening or causing death. Interventions which are specifically designed to hasten death, even when motivated by the desire to limit the suffering of the patient, family, or staff, must be avoided.
Kathleen Fenton, M.D.
Children's Health Care Services
1John Paul II, Evangelium vitae (March 25, 1995), n. 14.
2Catechism of the Catholic Church, 2nd ed., trans. United States Conference of Catholic Bishops (Vatican City: Libreria Editrice Vaticana, 1997), n. 2276.
3For example, see J.S. Tweddell and T.L. Spray, "Newborn Heart Surgery: Reasonable Expectations and Outcomes," Pediatric Clinics of North America 51.6 (2004): 1611_1623.