Tuesday, 03 January 2017 11:49

Preparing for Eternal Beatitude

Written by

End-of-life issues abound in modern culture.  Some western countries have had euthanasia and assisted suicide laws in place for years.  Other countries are gradually moving in that direction.  Medical societies are becoming more agreeable to the support of legalization of euthanasia. Some medical institutions and practitioners are beginning to endorse programs that place economics and institutional quality metrics ahead of the interests of individual patients. 

Acute care hospitals, palliative care programs, and hospice care are being shaped in many ways by reimbursement programs. Prevailing culture biases exist which evaluate human worth based on capacities for productivity.  These factors influence the movement towards creating registries of advanced care declarations for all persons across localities and even on a national basis.  Many of these advanced care plans are being developed and promoted by those same institutions and groups who are focused on service line provisions that try to balance demand for services with difficult cost containment objectives.  In light of these dilemmas family members of critically ill patients are often left wondering what they should be doing to properly care for their loved ones.  This report will provide some background and guidance to Christians who seek to live their faith in critical medical situations and witness to their allegiance to Jesus Christ in moments of difficulties associated with end-of-life care decisions.

What Makes Christian End-of-Life Ethics Unique?

For some, the meaning of one’s whole life story is impacted by the way they live their final days.  For some, the way they die has a great impact on their families, communities, and work associates.  How we live the final days of our life really matters.  It can be a time of drawing life’s lessons to a close, preparing for our eternal encounter with Jesus Christ, saying good-bye to loved ones, and if possible, reconciling with those who are estranged from us.  

For Christians, the hope we have to lean on at the end of life is Jesus Christ.  If we have died with Christ in this life through Baptism, we will live with Him forever in the next.  Bodily death is going to happen to all of us - but it is not the end of life.  By Christ’s death, the sting of our own death and the death of those we love who are in Christ has been lessened.  We know our future is in glory with God.  Sometimes, God gives us more than a brief time before death to prepare for this great reunion so that we can be reconciled with Him and with others.  At other times, God allows us to suffer a little and be purified before death.  What sets apart Christian end-of-life ethics from the secular perspective, is that Christians believe end-of-life suffering can have meaning for ourselves and for others.  The key to that meaning is a deep relationship with Jesus Christ and a willingness to follow Him and be configured to Him as we anticipate living with Him eternally.  

Moral Criteria for End-of-Life Decision Making 

All Christians have a duty to prepare for death spiritually even if we do not have the opportunity to prepare in a way that a long terminal illness provides.  When we are fortunate enough to have an extended period to prepare for death, or at least have the opportunity to make choices about how we spend our final days, we need to know the basis for moral decision making.  Life and health are precious gifts from God, and we have an obligation to be good stewards of our health; however, that obligation has limits.  We are called to use ordinary care to preserve life.  Extraordinary care is optional.  Ordinary care includes provision of food and drink (regardless of the means used to give it), as well as shelter and health care.  Artificial nutrition and hydration, when needed to sustain life, are included in ordinary care if they are able to nourish the body unless for some reason these are excessively burdensome for the patient.  Artificial nutrition and hydration are not required when death is imminent but should be provided if they give comfort to the patient.  The judgment on what constitutes ordinary care in a particular situation should be based on the effectiveness of the treatment not the quality of a patient’s life.

Extraordinary care can be used if the patient wishes, but it is not required.  Extraordinary care procedures and interventions may involve an excessive burden to the patient based on the determination of the patient or his/her proxy.  However, that extraordinary care can only be decided properly on a case-by-case basis, and it is important to note there is no blanket definition that applies to all persons at all times and in all circumstances.  Sometimes, there are extenuating circumstances that cause a patient to choose heroic interventions in order to have time to complete some important work or in order to attend some important event.  Once the matter is attended to, the patient may decide to dispense with extraordinary care. Eventual termination of extraordinary care that precipitates death is morally acceptable as long as death is not willed by removal of the extraordinary care and as long as ordinary care continues to be provided.

Pain management can be a serious concern for persons approaching end-of-life.  From a moral perspective it is acceptable to alleviate pain as long as the intention is to reduce or eliminate pain, not silently and comfortably kill the patient.  It should be recognized that people have different pain thresholds and different views on how much pain medication they need to receive. Patients have the right to consciousness to prepare for death and should not be so heavily medicated as to be put into a coma unless there is no alternative for dealing with pain, and even then, only if that is the wish of the patient.  Strong pain medications can reduce life expectancy, usually because they suppress respiration.  Strong doses of narcotics and other analgesics may be used to relieve pain, when needed and desired by the patient, but they should never be used for the purpose of causing death.

Euthanasia and Assisted Suicide

The commonly used definition of euthanasia is that it is an act or omission which, of itself or by intention, causes death, in order that all suffering may be eliminated.  Euthanasia is a grave violation of the law of God because it is a deliberate and morally unacceptable killing of a human person. This can be readily understood by all, and is based on natural law, Scripture, and Church teaching.   There are three different forms of euthanasia including voluntary (the patient requests the euthanasia), non-voluntary (performed on patients who cannot request it, for instance on infants or incompetent patients), and involuntary (done on a competent patient who does not want it).

Physician assisted suicide (PAS) is a form of voluntary euthanasia.  In the case of PAS, the physician intentionally helps another person, usually suffering from a terminal or chronically debilitating disease or condition, to take his own life.¹   Under most situations this is done by the provision of a lethal dose of a drug intended to kill the patient.  The original model of PAS involved the patient self-administering the deadly drug.  Now that has been modified to help people who are limited in physical ability (such as paralyzed persons) to take the drug.  In addition to the objective evil of physician involvement in killing and the premature death of a person, there is a great concern about the psychological health of the individual requesting PAS.  In many if not most places where PAS is legal, no requirement exists for psychiatric evaluation or treatment for mental illness, even though it has been reported that in the vast percentage of cases where PAS takes place, the person is known to suffer from depression.²   The argument exists that an individual who chooses PAS is exercising his/her autonomy, but the reality remains that depression reduces a person’s true autonomy, as one is not able to rationally address problems.  It is also true that in many places where PAS is legal that there is no mechanism to confirm that the patient is not being coerced by family members or close friends to end their lives. Unfortunately, not all individuals find support from those closest to them in times of need, and some are even pressured due to social or economic interests to end their lives.  Regardless of the rationale, PAS is always gravely immoral.

Preparing for End-of-Life Before It Approaches

Today there is a desire on the part of many physician and institutions to have all patients complete and maintain forms that declare their end-of-life wishes related to physical and medical care.  When it comes to completing forms that declare one’s end-of-life wishes, the number of options can be daunting and very confusing as well as legally risky.  These forms may include designation of health care surrogates to act as proxy if the patient cannot speak for himself/herself.  They also include living wills and advanced care directives.  As these forms have evolved, the terms are no longer definitive per se, but all give some set of instructions for patient preferences for end-of-life care.

‘Health Care Proxy’ or ‘Medical Durable Power of Attorney’ forms designate the names and contact information of persons who are chosen by the patient to act as the patient’s surrogate in medical decisions, should the patient be unable to represent himself for his own care.  Individuals selected to serve as health care proxies should know the patient’s wishes and be willing and able to speak on behalf of the patient.  A health care proxy should not be involved in any action or decision related to or condoning of assisted suicide or euthanasia; furthermore, their position obligates them to preserve the dignity and sanctity of life in all circumstances.

It is recommended that all individuals designate a health care proxy to serve for them if they become incapacitated.  That person should be able to represent a Christian approach to critical life care, including handling matters involving conflicts with medical providers and medical institutions.  It is important to talk with one’s proxy to clarify personal wishes and intentions.  It is also important that family members know who the health care proxy is, so that there is no added tension within the family based on the role of the proxy when medical decisions are needed.

Some advanced care directives, including living wills, designate health care surrogates.  They also declare preferences for such matters as when, or if, to administer artificial nutrition and hydration, oxygen, respiratory/ventilator services, antibiotics, dialysis, etc. in the event that such administration would be called for in order to ameliorate a medical problem.  If one completes an advanced care directive or living will that requests the elimination of ordinary care, he/she may be participating in euthanasia which is always immoral.  DNR (Do Not Resuscitate) forms are a specific advanced directive that indicates that the patient does not want to receive cardiac pulmonary resuscitation (CPR) in the case of cardiac arrest.  In some cases this may be morally permissible but not in all cases.  The specific situation will impact the morality of the DNR.

Another morally confusing end-of-life order is known as POLST, an acronym that stands for ‘Physician Order for Life Sustaining Treatment’.  This category of instructions includes different labels (such as MOLST and MOST) based on locality and depends on where the form is legal or where there is consensus regarding the use of the form. POLST forms are completed by a health care worker and signed by a physician.  Some POLST forms require patient signature and some do not.  In the USA these become legally binding orders for care and may be executed without discussion with the health care proxy.  The presumption behind these forms is that the patient’s life is drawing to a close and no particular changes are expected that would call for a reevaluation of the care plan.  A designated protocol is established to be followed in the event of a critical episode of care which has not yet taken place.  The protocol will be followed by those caring for the patient without exception.  These are promoted as helpful to expedite care for chronically ill patients.  They may also result in euthanasia.  Due to the ethical dilemmas these forms can cause, it is recommended that patients do not agree to the use of POLST.

There are many ethical issues involved in the health care directive forms mentioned above.  It is beyond this summary report to cover them thoroughly.  However, be advised that Christians should always make sure that they are accepting ordinary care for the situation they are in and should not refuse ordinary care in their declarations of intentions for future care.  One should avoid using detailed specifications about types of care desired in advance of a medical need because interpretation of these instructions becomes problematic; the circumstances and details of the actual medical episode will impact what care protocol is morally necessary.  The easiest way to avoid being overly, and/or inappropriately prescriptive, is to have a health care proxy statement and avoid completing detailed living wills and avoid use of POLST forms.

A Call to Accompaniment

The Christian World-View

As Christians we should accompany one another rather than allow our brothers and sisters to suffer in isolation and depression, particularly at moments of severe illness and impending death.  People often say pain is the reason for suicide or euthanasia.  In fact, it is often not pain.  It is hopelessness.  Pain can usually be alleviated.  Hopelessness takes more time as it involves the family and community offering solace to the suffering person and walking with him/her in solidarity.  This is counter-intuitive for a culture that avoids grief and avoids dealing with primordial fears such as one’s own fear of death.  In addition, the brokenness of many families complicates matters for the patient.  People of faith need to extend themselves especially to those who have lost hope.  We must strive to discover the truth of the good of every human person based on the nature of being human and not the circumstance of their lives.³  

The Secular World-View

Autonomy and self-determination as defined in our secular culture can create conflicts in moral decision making in end-of-life situations.  A mistaken understanding of freedom-of-choice-- which can inappropriately promote radical autonomy--will foster alienation rather than solidarity. When that is the driving principle of life, people in need can be left alone and unsupported.   In other situations, people value autonomy and self-determination to such a degree that they equate dignity to not being dependent on others.  For this reason, some individuals prefer euthanasia to dependency on caretakers. This is an error in understanding of the meaning of one’s dignity which does not equate with one’s functional abilities.  Rather, one’s dignity comes from God and is implicit in the value of being human, regardless of any arbitrary level of “productivity”.  

Cost controls and a sense of futility of life can compromise medical decision-making. Medical institutions running under tight budgets may set policies to move people out of their institutions as soon as possible when it appears that no medical cure is available or when insurance calls for limited or no reimbursement.  Sometimes, when available, efforts are made to find suitable arrangements for palliative care, but in other cases individuals are left to fend for themselves when they no longer fit the institutional model of health care.  Medical practitioners sometimes allow their cultural bias to influence when care should be rescinded.  This can be done without the input of the patient and may go so far as to open the door to passive or active euthanasia.  Such has been shown to be the case where euthanasia has been legal for years.  Research has shown that discrimination in medical care does indeed happen in those groups that are already comprised by poverty, lack of access to medical services, or are members in a stigmatized group (like the mentally or physically handicapped).

Seeking Mercy 

sister cecilia mariaWhen do we need God’s Mercy and renewal in regard to end-of-life matters?  When we realize we have ignored the suffering and the dying among us.  We need God’s Mercy when we have directly or indirectly assisted someone in cutting short his or her last days by eliminating or withholding ordinary care.  We need God’s Mercy when we have insisted we will order our final days according to our own desires, denying God the basic obedience that we are called to by accepting care that He has defined, through His Church, as ordinary and therefore obligatory.  We need God’s Mercy when we have given bad example and/or bad advice to others as they were making final arrangements for their own or another’s death.  We need God’s Mercy when we have participated in any act of suicide or euthanasia, no matter what the role we might have had in this act.  When we ask for God’s Mercy because we have failed, He will always grant it.  We need only ask with a contrite heart.  When we would not reach out and offer assistance to the wounded and dying and bereaved among us, Christ tells us, come to Me and I will lift you up and restore you.  I will give you a new hope and a new strength, humbled by failure, to begin anew.

We are called to give priority to love and imitate the Master.  “God is love, and he who abides in love abides in God, and God abides in him.”   A Christian knows that his life does not end here.  As he faces death, his end-of-life, his decisions either mirror the nobility of his life or create a new platform of hope to press on to the journey ahead, not looking back with remorse but looking ahead with expectation and even joys. One’s faith in God makes all the difference in the final crescendo of life.  Let us die as we have been called to live, as servants of God, our Heavenly Father, who loves us all as His children, beyond all telling.

 

Picture: Sister Cecilia Maria in her final days.

 

¹ While PAS was originally promoted to aid terminally ill patients, it is now being extended to disabled persons, persons who are greatly dissatisfied with their lives, and others who are not actually in the process of dying.

² Information relates to experience in Oregon, USA, where PAS has been legal for some years.

³ John Paul II:  Veritatis Splendor # 48, 1993.  “The human person cannot be reduced to a freedom which is self-designing but entails a particular spiritual and bodily structure. The primordial moral requirement of loving and respecting the person as an end and never as a mere means also implies, by its very nature, respect for certain fundamental goods, without which one would fall into relativism and arbitrariness.”  One of those basic goods includes solidarity with persons in situations that are difficult and painful.

 

Sources used for this article: John Paul II, Evangelium vitae, #65, 1995.

Dr. Knouse is a professional Catholic bioethicist who focuses on developing education materials and delivering instruction to clergy, teachers, students, and adult audiences on various topics related to beginning-of-life and end-of-life ethics.  She is able to draw from her extensive health care experience to bring a broad perspective to current issues while giving guidance that is actionable for her audiences.  Dr. Knouse also works with families in crisis during critical medical events to aid them in understanding the ethical implications of proposed medical interventions for loved ones who are dealing with an unanticipated health crisis.  

Dr. Knouse is passionate about helping those interested in practicing their Christian faith in those areas that pertain to the Gospel of Life.  She has a doctorate and a license in bioethics from Regina Apostolorum Pontifical University in Rome as well as a Master’s of Science in Health.  Through Esther Associates LLC, Dr Knouse provides consulting services as well as educational services in the fields of bioethics and health care.