ABSTRACT
Death with Dignity: The Future of Catholic Healthcare in Texas Regarding End of Life Policies The Texas Advance Directives Act of 1999 from a Catholic Perspective on Sanctity of Life
Ivy Jo Stejskal
Director: Bill Neilson, M.D.
The Texas Advance Directives Act of 1999 was a law that was created with the intention of adding order to the chaos that surrounded end of life care disputes. This act allows a physician to discontinue life-sustaining treatment if an ethics committee decides that the care of the patient is futile. Futile is termed as pointless or fruitless. The Catholic Church has very strict and set doctrine on how end of life issues should be handled as well as what constitutes a human person. The Catholic Church also has set doctrine on how to preserve the sanctity of a person even in the hours of death. My thesis will assess both the laws in place in Texas as well as the teachings of the Catholic Church regarding end of life care. Through this understanding, we will address certain case studies and how each of these would have been decided using the ERDs, TADA, and a combination of these two documents as a guide. After discussing the relations between politics and religion and how this impacts the delivery of end of life care, I will present the reason behind why an issue like this is important to me as well as my audience. There are faces and names behind all of the data and end of life care statistics. This thesis was designed to advocate for people in their last hours here on earth.
APPROVED BY DIRECTOR OF HONORS THESIS:
______
Dr. Bill Neilson, Honors Program
APPROVED BY THE HONORS PROGRAM:
______
Dr. Andrew Wisely, Director
DATE: ______
DEATH WITH DIGNITY: THE FUTURE OF CATHOLIC HEALTHCARE IN TEXAS REGARDING END OF LIFE POLICIES
THE TEXAS ADVANCE DIRECTIVES ACT OF 1999 FROM A CATHOLIC PERSPECTIVE ON SANCTITY OF LIFE
A Thesis Submitted to the Faculty of
Baylor University
In Partial Fulfillment of the Requirements for the
Honors Program
By
Ivy Jo Stejskal
Waco, Texas
May 2015
TABLE OF CONTENTS
Chapter One: Introduction to Catholicism and Texas Law...... 1
Chapter Two: Death and Dying-A Catholic Perspective ...... 8
Chapter 3: The Texas Advance Directives Act of 1999 ...... 23
Chapter 4: The Practical Application of Catholic Doctrine Within Hospital Walls . 33
Afterword: Shining Light in the Darkness...... 52
Bibliography...... 59
ii
CHAPTER ONE
Introduction to Catholicism and Texas Law
“But of that day and hour no one knows, not even the angels of heaven, nor the
Son, but the Father alone”1 (New American Standard Bible). No one knows when he will
die, nor does he know how he will die. The timing of death is something that is known only to God. Even if one has endured almost 20 years of schooling, dons a freshly starched long white coat, and has a framed medical school diploma, he still does not have this knowledge of the hour of death. Patients die from accidents, cancer, and infections but from a Catholic perspective never should they die by the hand of their physician
(Catechism of the Catholic Church). When death, medicine, and religion combine they produce difficult conflicts, but the addition of government, laws, and policies makes healthcare even more challenging. As healthcare is changing, the issues of end of life care come to the forefront of this discussion.
The end of life care issues to be discussed in this thesis are only the beginning when it comes to the many medical ethics topics that challenge the beliefs of the Catholic
Church. One of the most recent challenges within Catholic healthcare is the Affordable
Care Act (ACA). The enactment of this law is going to have a profound effect on
Catholic hospitals across the United States and it is going to bring up new areas of concern. These areas of concern within the ACA include but are not limited to conscience laws and their impact on issues such as abortion, euthanasia, sterilizations, federal executions, and birth control. Conscience laws are federal regulations that protect
1 providers if they rightfully refuse to provide a treatment that is against their moral
standards (Collins English Dictionary, 2012).
Another concern for Catholic healthcare is the loss of Catholic identity. One main
reason this is occurring is because Catholic hospitals have lost the prominent positions of
religious sisters within the hospital. This decline of nuns in the role of nurses and health
professionals can be illustrated by an interview done with Sr. Mary Jean Ryan from St.
Louis. When Sr. Mary was a nurse in the 1960s, a nun ran almost every department
within the big Catholic Hospital where she worked. Now only 11 nuns remain out of the
22,000 Catholic Hospital employees2 (Kevin Sacks, 2011).
Religious orders had been in charge of healthcare delivery and medicine long before the government had a role in healthcare financing. St. Elizabeth of Hungary and the Franciscan monks felt it was in their vocation as religious officials to care for the sick, dying, needy, and hungry. The monks and nuns felt that they needed to be the hands and feet of Christ especially to the poor and vulnerable3 (Thomas Nairm, 2010).
Catholic hospitals were built with this mission of helping the underserved and maintaining Catholic doctrine in the 13th century. Catholic hospitals came to the United
States in the 1700s and today there are over 400 Catholic hospitals4 (James Walsh).
Currently, this Catholic mission is being tested by outside influences such as the ACA
and non-religious leadership. For some of the Catholic hospitals, the only thing that
makes them Catholic is that they have the word ‘Saint’ in their name or they may have a
priest living in residence. Some Catholic hospitals are now having a harder time honoring
their original mission of serving the underserved and providing quality healthcare to the
needy (Lilly Fowler, 2015). A large percentage of Catholic hospitals are more concerned
2 with making money than upholding Catholic doctrine and caring for the disadvantaged5
(Alan Zuckerman, 2005). This concern with money over mission is a natural trend that
may have happened because Catholic hospitals are forced to compete with other large hospital systems. Catholic hospitals are now hiring CEOs based upon their ability to run a
business regardless of whether they are Catholic or not6 (Andrew Agwunobi, 2013).
The seven issues presented in the chart below are issues of particular concern with
Catholic healthcare providers as of 2005. The scales on the chart range from 1 (strongly disagree with the statement) to 7 (strongly agree with the statement). As can be seen by this chart, Q23 states that financial skills in a CEO are on the same level as upholding
Catholic values. Q23 is almost a 6 on the scale of 1-7 meaning that out of the 175
Catholic healthcare providers surveyed, most of them strongly agreed with the statement in Q23. Also in the chart below, Q24 is a huge concern that suggests that Catholic hospitals could lose their original vision. Q24 states that a majority of the providers surveyed agree with the statement that it may be necessary to close programs for the poor in order to keep Catholic hospitals open. Catholic hospitals were originally created to help the poor and needy and this chart implies that Catholic hospitals may need to close their programs for the poor (Alan Zuckerman, 2005). Q23 and Q24 are at the core of what makes up a Catholic hospital: a mission to uphold Catholic doctrine and help the poor. The data presented in this survey shows that money and financial concerns have consumed the mind of Catholic healthcare administrators and the Catholic identity of the hospitals may end up lost because of this.
3
Figure 1: Issues Within a Catholic Hospital
The Affordable Care Act (ACA) is going to greatly affect the future of Catholic
healthcare. If Catholic hospitals work to regain their original purpose, these hospitals
offer an alternative to what could become government run healthcare. The ACA will
challenge Catholic beliefs on conscience issues such as abortion, euthanasia, sterilizations, and contraception among other issues. An interview with Leonard J. Nelson
III, a professor at the Cumberland School of Law at Samford University and author of a
book addressing the future of Catholic healthcare, said that if a Catholic hospital were forced by ACA to provide abortions or abortion referrals, it would either be shut down for refusing this service or taken over by non-Catholic facilities7 (Leonard Nelson, 2013).
Jesuit Father John Haughey, a research fellow at Georgetown University’s
Woodstock Theological Center, focuses on the role of Catholic healthcare as a way to
imitate Christ’s healing ministry. He had these words to say on the future of Catholic
4 healthcare:
What people should experience through Catholic healthcare is ‘more than competence, though that, more than efficiency, though that too, more than professionalism, though that too. It is people giving of themselves, emptying themselves to serve their brothers and sisters. … If that is what is experienced in your facility,’ he said, ‘you are extending Christ’s healing mission in that facility at this time’8 (John Haughey, 2012).
Even with outside influence impacting Catholic healthcare providers, it is still possible to
be a doctor and a devout Catholic.
The future of Catholic healthcare seems uncertain under the ACA, but in a narrower sense, end of life care is also an area that needs to be given great thought as it
pertains to governmental regulation. The Catholic Church has very strict and set doctrine
that went into the formation of the Ethical and Religious Directives (ERDs). The ERDs
discuss how end of life issues should be handled as well as what constitutes a human
person. Texas law, the Texas Advance Directives Act of 1999 (TADA), is also working
in the same manner as the ERDs in trying to regulate end of life care disputes. This act
allows a health care facility to discontinue life-sustaining treatment if an ethics committee
decides that the care of a patient is futile or essentially non-beneficial.
The original idea for this thesis was that the Catholic Church and the Ethical and
Religious Directives were in direct conflict with the Texas Advanced Directives Act. It
was thought that TADA did not take into consideration the sanctity of the human person,
as did the Catholic Church and therefore was working against the ERDs. It was also
thought that TADA was not upholding the dignity of the person by allowing for this
termination of treatment. What was found to be true was that the ERDs and TADA were not in direct conflict with each other. Since Catholics have such a strict and set definition
of what makes up a human life, there is the potential for differing views on what
5 constitutes a human person. In the following chapters, both the teachings of the Church on end of life issues as well as the laws in place in Texas concerning death will be addressed. Finally, the similarities and differences between TADA and the ERDs will be observed when applied to cases of a baby with anencephaly, Terri Shiavo, Karen
Quinlan, and Emilio Gonzalez.
6 Endnotes
1. New American Standard Bible (NASB) (Matthew 24:36)
2. NY Times Interview with Sister Mary Jean Ryan discussing how the roles of nuns have changed in the past 60 years. The total number of nuns in the US has declined and nuns have move from their performance in medical ministry to other roles.
3. The Catholic Tradition of Healthcare-A leading Franciscan ethicist explains why Catholics are committed to ensuring good health: We've been in it from the beginning. This article discusses the 5 main values in Catholic Healthcare and contemporary challenges of Catholic Healthcare today. Thomas Nairn, O.F.M., is the senior director of ethics at the Catholic Health Association of the United States. He holds a Ph.D. from the University of Chicago Divinity School.
4. History of the Catholic Church from the Catholic Encyclopedia.
5. Catholic Healthcare’s Future. Alan Zuckerman, director of Health Strategies & Solutions, Inc., Philadelphia discuses issues likely to affect Catholic hospitals over the next 5 years.
6. 'Catholic' Hospitals vs. Hospitals: Rediscovering the Difference. Dr. Andrew Agwunobi is a leader of the Hospital Performance Improvement practice at Berkeley Research Group. This article discusses the current era’s change in Catholic Healthcare.
7. Catholic Health Care in the Age of Obama-What happens when government regulations conflict with Catholic ethics? Interview with Jack Nelson a professor at the Cumberland School of Law, Samford University, Lister Hill Center, and University of Alabama Birmingham School of Public Health.
8. Jesuit Father John Haughey, a research fellow at Georgetown University’s Woodstock Theological Center discussed the future of Catholic Healthcare.
7
CHAPTER TWO Death and Dying: A Catholic Perspective
Catholicism is a denomination with a substantial amount of written doctrine.
While Catholics believe the Bible is inerrant (without error) and inspired by God, they do follow other doctrine in order to define their faith. Catholicism uses the Bible as the base
of understanding and knowing God. It is from this understanding of God that truth is
found. Some other types of truth that Catholics use are documents that have been written
by the pope called Papal Encyclicals and documents written by bishops under the guidance of the Pope (USCCB, 2009). Papal Encyclicals are written by the pope, who is the leader of the Catholic Church on earth. What the pope writes while he is in the office of pope is true and binding for all practicing Catholics (Robert Brom, 2004). The pope works to define the faith and make what the Bible says into applicable steps that lay people can use on a daily basis to uphold the faith. Vatican II commented on papal infallibility saying,
The pope enjoys in virtue of his office, when, as the supreme shepherd and teacher of all the faithful, who confirms his brethren in their faith (Luke 22:32), he proclaims by a definitive act some doctrine of faith or morals. Therefore his definitions, of themselves, and not from the consent of the Church, are justly held irreformable, for they are pronounced with the assistance of the Holy Spirit, an assistance promised to him in blessed Peter (Robert Brom, 2004).
Because Catholicism is based on Scripture and Tradition, the historically
accumulated documents still reign true for Catholics unless they contradict Catholic
8 moral code. Pope Francis recently commented on the Catholic idea of scripture and
tradition:
The Holy Scriptures are the testimony in written form of God's Word, the canonical memorial that attests to the event of Revelation. The Word of God, therefore, precedes and exceeds the Bible. It is for this reason that the center of our faith is not only a book, but a history of salvation and especially a Person, Jesus Christ10 (Pope Francis, 2013)
The United States Council of Catholic Bishops (USCCB) has participated in the
formation of Catholic doctrine in accordance with both Scripture and Tradition. The
USCCB has written on topics ranging from birth control, to the Mother of God, to life,
and then ultimately to death. Some of the most important as well as controversial teachings of the Church are the ones that deal with life and death. The present issue that is at the forefront of the minds of recent popes and bishops while forming doctrine is the preservation of human dignity and worth. Pope John Paul II (1978-2005) wrote
extensively on the topic of human dignity, abortion, euthanasia, and the upholding of
Catholic Doctrine in medicine. At around the same time, the USCCB released a
document called the Ethical and Religious Directives for Catholic Healthcare Services
(ERDs). This document, first released in 1971, has released five updated editions since
then including the most recent update in 2009. (The Right to Health Care: Social
Responsibility and the Health Care Issue). The ERDs give Catholic physicians,
healthcare workers, and patients the stance of the Catholic Church about the sanctity of
humanity in the medical field. The goal of the ERDs is to ensure that Catholic hospitals
and health professionals have a guide to understand Catholic moral doctrine as they
practice in the secular world of medicine. The chapter of the ERDs most applicable to
this thesis is Chapter 5: “Issues and Care for the Seriously Ill and Dying.” Before moving
9 further, it is important to understand the foundation of Catholic Healthcare using the
ERDs as a guide. In a discussion with Fr. Timothy Vaverek on the infallibility of
Catholic bishops and papal speeches, he had this to say: “Failure to abide by the ERDs would be disobedience, but not per se a crime of heresy. However, failure to believe and act according to the doctrine upon which the ERDs are based certainly would be heresy.
The nuance is that the ERDs and papal speeches do not establish anything as doctrine, but they may repeat already established doctrine.” What Fr. Vaverek is saying here is that the
USCCB founded the ERDs on already established Catholic doctrine that was previously made infallible by the Pope. When any aspect of the ERDs express doctrine, they are to be followed by Catholics. If portions of the ERDs are opinions or not backed by the Pope then those would not be binding for Catholics. Fr. Vaverek also said that the ERDs are not a direct encyclical from the Pope and that “they are not, as they stand, a national policy. They are a set of proposed policies recommended by the USCCB to individual bishops for use in their dioceses. They have no canonical force unless a bishop makes them norms in his diocese” (Timothy Vaverek, 2015).
The ERDs start out with a passage describing how every medical provider should approach someone who is under his care. “One of the primary purposes of medicine in caring for the dying is the relief of pain and the suffering caused by it”12 (USCCB, 2009, pg 29). When one is called to medicine he should do everything he can to lessen suffering and recognize human dignity. The Christian Medical and Dental Association released a statement on suffering saying that suffering causes a patient to lose himself deep within his disease and it is the duty of Christian doctors to pull people from the depths of their suffering and help them become whole again. If physical suffering cannot be eliminated,
10 if the disease is too ravenous, if the expense is too much, or if the burdens of treatment outweigh the benefits, then the only thing left for doctors to do is to help their patients cope. Physicians are to step into the suffering with their patients and help them understand the reasons behind their suffering and pain (Christian Medical and Dental
Association, 1993). Pope Leo XIII addresses suffering and quotes 2 Timothy and 2
Corinthians in his encyclical Rerum Novarum (Of Revolutionary Change) focusing on the nature of labor duties of the working class and equality between all members of society.
Christ's labors and sufferings, accepted of His own free will, have marvelously sweetened all suffering and all labor. And not only by His example, but by His grace and by the hope held forth of everlasting recompense, has He made pain and grief more easy to endure; for that which is at present momentary and light of our tribulation, worketh for us above measure exceedingly an eternal weight of glory13 (Pope Leo XIII, 1981)
Suffering will always exist but it has been made easier to handle because of the suffering and death Jesus had to withstand. Catholic medical providers (or just good human beings) have to be able to give their patients the type of medical care that might not involve medications or procedures, but instead, love and prayers. This passage of the
ERDs gives a glimpse of the idea that in order to fulfill the duties of Catholics and medical professionals the provider has the responsibility to be a rock for the suffering and an open heart for the weary.
The ERDs are to be used as a tool to help direct Catholics during difficult times and even tougher decisions. When Catholics are in a dilemma, they can look to Catholic doctrine written on the subject in question to help decide how to proceed. This following passage from the ERDs answers the questions often posed by Catholic healthcare providers, patients, and family members: How much treatment is too much and where is the line drawn in ending life-sustaining treatment?
11 The truth that life is a precious gift from God has profound implications for the question of stewardship over human life. We are not the owners of our lives and, hence, do not have absolute power over life. We have a duty to preserve our lives and to use them for the glory of God, but the duty to preserve life is not absolute, for we may reject life-prolonging procedures that are insufficiently beneficial or excessively burdensome. Suicide and euthanasia are never morally acceptable options4 (USCCB, 2009, pg 29).
Within this paragraph lies a message to all Catholics but one that is easily
applicable to doctors and nurses. “We have a duty to preserve our life and to use it for the glory of God”15 (USCCB, 2009, pg 29). In the midst of the chaos of the Emergency
Department, in the craziness of the OR, and in the piles of paperwork, Catholic
physicians may be comforted by understanding that they are not doing this to glorify
themselves; they are God’s servants on earth. If they are overworked and overwhelmed,
they are to give it all to the glory of God and allow themselves to be the hands and feet of
Christ in every single life they touch. In the words of Pope Francis to millions of youth at
World Youth Day in Brazil in 2013: “Go, do not be afraid, and serve. Evangelizing
means bearing personal witness to the love of God, it is overcoming our selfishness, it is
serving by bending down and washing the feet of our brethren as Jesus did”16 (Pope
Francis, 2013).
The next piece of guidance this passage gives alludes to the difficulty in handling
a patient who is near death. This is equally applicable to physicians, patients, and close
family members. “We may reject life-prolonging procedures that are insufficiently
beneficial or excessively burdensome”17 (USCCB, 2009, pg 29) When the burdens of the
life-prolonging treatment outweigh the good the treatment is doing then it is not against
Catholic doctrine to withhold or remove the treatment from the dying patient. For
example, if a patient suffers from infection after infection due to the treatment designed
12 to save his life, it is within reason to remove the treatment that is causing the deadly,
painful infections and let the disease naturally take its toll, managing the patient’s pain
along the way.
In dealing with death, the Principle of Double Effect is important. This idea
comes from St. Thomas Aquinas’s writings on death in Summa Theologica. This
principle has many facets but it is used by Catholics as a guide in making correct moral
decisions. “The New Catholic Encyclopedia provides four conditions for the application
of the principle of double effect:
1. The act itself must be morally good or at least indifferent. 2. The agent may not positively will the bad effect but may permit it. If he could attain the good effect without the bad effect he should do so. The bad effect is sometimes said to be indirectly voluntary 3. The good effect must flow from the action at least as immediately (in the order of causality, though not necessarily in the order of time) as the bad effect. In other words the good effect must be produced directly by the action, not by the bad effect. Otherwise the agent would be using a bad means to a good end, which is never allowed. 4. The good effect must be sufficiently desirable to compensate for the allowing of the bad effect” (New Catholic Encyclopedia).
To put these steps into action, an example from the Stanford Encyclopedia of
Philosophy is helpful in this scenario.
A doctor who intends to hasten the death of a terminally ill patient by injecting a large dose of morphine would act impermissibly because he intends to bring about the patient's death. However, a doctor who intended to relieve the patient's pain with that same dose and merely foresaw the hastening of the patient's death would act permissibly (Stanford Encyclopedia of Philosophy, 2004).
The intent behind the action is key in determining the morality behind the action. This is consistent with correct Catholic moral teachings. The goal should be to preserve the
13 sanctity of human life at all costs, even if that means lessening pain to provide comfort
and dignity with the negative effect flowing from this act being death.
Continuing with the passage on benefit and burden, it leaves readers with the
statement “Suicide and euthanasia are never morally acceptable options”18 (USCCB,
2009, pg 29). Euthanasia is defined by the Catholic Church in the Catholic Catechism as follows:
Direct euthanasia consists in putting an end to the lives of handicapped, sick, or dying persons. It is morally unacceptable. 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 person and to 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 excluded19 (Catechism of the Catholic Church).
In short, anything done to prematurely end the life of the vulnerable outside the
means stated above in the ERDs is considered euthanasia or essentially murder. If
treatment is of normal means, causing no problems, and is working to prolong and better the life of the patient and one removes this treatment, then he has committed the sin of
euthanasia, violating the Catholic doctrine within the ERDs as well as the fifth of the ten
Commandments, “Thou Shall not Kill”20 (New American Standard Bible-Exodus 20:13).
Deep within the ERDs a short but powerful sentence is found. “The task of
medicine is to care even when it cannot cure”21 (USCCB, 2009, pg 29). Humans have
limited knowledge. Doctors have to be able to know when they have reached the limits of
their profession. They have to know when it is best to put down a textbook and use the
power of human words and kindness. The Gospel of John commands just this. “This is
how all will know that you are my disciples, if you have love for one another”22 (New
American Standard Bible-John 13:35). When someone is knocking at death’s door, a
14 good physician has to be able to know what his dying patient needs. At that time, the
patient does not need another medication or another test. He needs to know that he is
loved, cared for, and that his family is at peace. A doctor now becomes a doctor of the
soul instead of a doctor of the body. The ERDs are making a point here that doctors have
limits. They are not required to prolong life at all costs but they are required to maintain
the dignity of human life at all costs.
In discussing end of life care, it is inevitable that the idea of nutrition and
hydration for the dying and comatose would need to be addressed. This topic was of
enough concern that the USCCB needed to add this crucial piece of information to the
ERDs in the 1990s:
“The Church’s teaching authority has addressed the moral issues concerning medically assisted nutrition and hydration. We are guided on this issue by Catholic teaching against euthanasia, which is ‘an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be 23 eliminated’ (Franjo Cardinal Seper, 1980).
“While medically assisted nutrition and hydration are not morally obligatory in certain cases, these forms of basic care should in principle be provided to all patients who need them, including patients diagnosed as being in a “persistent vegetative state” (PVS), because even the most severely debilitated and helpless patient retains the full dignity of a human person and must receive ordinary and proportionate care”24 (USCCB, 2009, pg 30).
As stated above, “A person has a moral obligation to use ordinary or
proportionate means of preserving his or her life. Proportionate means are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community”25
(USCCB, 2009, pg 31). Father William Saunders, in his article on the Catholic Teaching
on Euthanasia, stated that it is difficult to determine what is extraordinary care. One
cannot always say, for example, that a ventilator is extraordinary care. When a treatment
15 offers a reasonable hope of recovery then it is ordinary care; when a treatment is simply prolonging death it becomes extraordinary because it starts causing more of a burden than a benefit. Fr. Saunders stated, “None of these cases are easy. However, there is a great difference between purposely killing someone and allowing a person to die peacefully with dignity”26 (William Saunders, 1994). Looking closer at these last two passages,
Catholics are given some guidance about how to handle situations such as cases similar to the Terri Schiavo case. This case brought up a dilemma rarely seen: conflict between a husband and the parents of a woman in a vegetative state. For over a decade, Schiavo was unresponsive after collapsing in her home. Schiavo’s husband eventually realized that furthering treatment would be futile and requested that his wife’s tube feeding be stopped. His request was disputed by Schiavo’s parents who believed that she was still alive and would come out of her vegetative state. They wanted every life sustaining measure taken for their daughter. This case was taken to the courts only to be fought over and appealed numerous times without any progress. Fifteen years after the initial incident, the decision was made to remove Schiavo’s feeding tube and she died two weeks later27 (Terri Schiavo-Life and Hope Network). This case of Terri Schiavo is difficult and challenging even for the most veteran physicians. Decisions like these are made easier for physicians seeking guidance through the use of the ERDs. According to the ERDs a patient has the right to anything that is ordinary care such as food and water as long as these things do not cause adverse effects. The basic necessities are no longer of ordinary means when they become oppressive or burdensome to any party involved. If the tube feeding is causing deadly infections, then it is acceptable to stop the tube feeding that was designed to sustain the patient’s life so he does not die a horrible death by
16 infection. The ERDs also imply that excessive expense is also a means by which ordinary
treatment such as nutrition and hydration can be stopped. If the family is left in a great
amount of debt as a result of the life sustaining treatment then the financial burden is
enough of a burden to outweigh the benefits of this treatment. It is also necessary,
although a difficult topic to discuss, to note that being a burden on society is another way that the removal of treatment can be morally justified. It is difficult to determine when someone has crossed the line from proportionate care to extraordinary care which makes for a difficult decision for family members when this situation arises. The ERDs do give some type of regulation to this gray area which is helpful for Catholic providers and family members, but each case comes with its own set of challenges. The ERDs may not provide an answer in these difficult circumstances.
In addition to the ERDs, when it is up to the family to decide how to proceed in end of life situations, the members will often turn to clergy. They may talk with their priest from their home parish or the Catholic chaplain of the hospital to ensure that what they choose for their loved one is still in line with Catholic teachings and still works to preserve the sacredness of every human life. In difficult times, physicians may fall into the role of clergy themselves. They not only provide a diagnosis and treatment, but they help guide the patients in making these tough decisions as well as give them a ray of hope to hold on to in the darkest of hours. With this being the case, a physician must be firm in his beliefs before tending to the needs of his patients. A physician is dealing with the tough questions in life. Medicine is a constant inner battle of right and wrong and if a physician is wavering in his own beliefs then the lives that are entrusted into his hands are in a very vulnerable position. In the same sense it is almost a requirement today for a
17 physician to take on the role of a doctor, counselor, and priest. “The nature of illness and
healing makes it inevitable that physicians will take on ministerial functions in their
medical work”28 (David Barnard, 1985). This idea of physician as priest provides comfort
in the fact that ideally every decision a Christian doctor would make is rooted in the solid
understanding and trust in God. Some doctors solely perform their role as physician and
end their responsibility there. For Christians, it should be only natural to fall into the dual
roles of physician and priest.
The ERDs also make a point that it is important for Catholics, in order to make
the dying process easier for all involved, to have an advance directive or living will. In
the event that one can no longer make decisions for himself, having his wishes written down makes the family’s decision about how to proceed a bit easier. “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” 29 (USCCB, 2009, pg 31). As long as what is in the will complies with Catholic teaching, then the final wishes of the patient
should be followed. It is difficult though if one is young and going in for routine surgery or gets into a tragic car accident and ends up with a deadly infection or life threatening
injury. A young person may not have a living will and may not have ever talked about his
dying wishes. This is when a Catholic family should turn to the Catholic teachings on end
of life care as well as priests and religious sisters to guide the treatment of the young patient. The USCCB makes it a priority that at the end of life, the dignity of the person and the sanctity of life is preserved and honored.
Patients should be kept as free of pain as possible so that they may die comfortably and with dignity, and in the place where they wish to die. Medicines
18 capable of alleviating or suppressing pain may be given to a dying person, even if this therapy may indirectly shorten the person’s life so long as the intent is not to hasten death30 (USCCB, 2009, pg 32).
If someone is able to live a miserable, painful six months without pain
medications such as morphine or live two great, comfortable weeks on morphine then the
second option is preferred. It is not always necessary to prolong life if one has to suffer
immensely. While Jesus does call us to take up our cross and follow Him, we do not have
to stand unbearable suffering here on earth in order to live with Him in Heaven. To live a
life without great suffering and with dignity is the ideal goal of any hospice or palliative
care provider. The goal of the doctor who is working to alleviate pain is to do just that,
use the medication to alleviate the pain and not interfere with the dying process. This
scenario preserves the sanctity of the life of that patient and makes the last few moments
of life, moments to be filled with God’s love not filled with suffering. “Society as a
whole must respect, defend and promote the dignity of every human person, at every
moment and in every condition of that person's life”31 (Pope John Paul II, 1995).
Catholics regularly turn to literature such as the ERDs to guide their decision
making in day to day activities as well as in big, potentially life ending, decisions. Local
bishops also interpret the ERDs to the people within their own diocese. The ERDs are a
good summary of Catholic beliefs and are trusted Catholic doctrine used by many
scholars, ethicists, and doctors today. Death is a difficult time even for doctors who have
been around it their entire careers but it becomes a little easier to handle for all those involved if they know that the steps they took in the dying process were in alignment with their core beliefs as Christians. The ERDs offer guidance on how to be a good, compassionate doctor even during the most trying times. In the stress and fast pace that is
19 medicine, it is difficult to remember that doctors are not the ultimate healer, God is.
Christian doctors need to keep God at the forefront of medicine. They cannot just call on
Him during difficult times such as death; He needs to be in every interaction they have with their patients. It is through God that they can be fully present in the suffering of their patients and be able to be their safeguard amidst the treacherous waters of sickness and death. The Ethical and Religious Directives help physicians to never lose sight of the fact that each patient is a child of God. His dignity and worth are immeasurable with the Lord and it is the duty of physicians to maintain this dignity, as they are the earthly doctors to their Father’s children. “See how great a love the Father has bestowed on us, that we would be called children of God; and such we are. For this reason the world does not know us, because it did not know Him. Beloved, now we are children of God, and it has not appeared as yet what we will be. We know that when He appears, we will be like
Him, because we will see Him just as He is”32 (New American Standard Bible-1 John
3:1-2).
20 Endnotes
9. The Ontario Consultants of Religious Tolerance wrote a guide to the history of the inerrancy of the Catholic Church from the early church to today.
10. Vatican Radio: The voice of the Pope and the Church in dialogue with the World. On 12/4/2013 Pope Francis addressed the world with this statement on Scripture and Tradition.
11. John Paul II wrote the Papal Encyclical, Evangelium Vitae, in order to stress the worth and dignity of each life. This encyclical also discusses artificial reproduction, abortion, euthanasia, the culture of death, and upholding God’s commandment to love your neighbor as yourself.
12. ERD Part 5-Issues and Care for the Dying Introduction
13. Pope Leo XIII discussed in his encyclical, Rerum Novarum, the rights and obligations of a working man. He discusses, wages, property owning, the formation of unions, and legal issues in the workplace. Leo connects work to suffering in saying that we are made for temporary, perishable things on earth but everlasting happiness in heaven. On earth we will face suffering and burdens in work, illness, etc, but we are to look to Jesus’ suffering on the cross as our example.
14. ERD Part 5-Issues and Care for the Dying Introduction
15. ERD Part 5-Issues and Care for the Dying Introductiom
16. Vatican Radio: The voice of the Pope and the Church in dialogue with the World. World Youth Day is a gathering of young Catholics from around the world. Pope Francis gave a homily to these young people asking them to go out a serve. He was instructing them to serve because Jesus is counting on them to love his creation. God will be with them but they need to be His servants while here on earth.
17. ERD Part 5-Issues and Care for the Dying Introduction
18. ERD Part 5-Issues and Care for the Dying Introduction
19. Catechism of the Catholic Church: Section 2277
20. New American Bible (NASB) Exodus 20:13
21. ERD Part 5-Issues and Care for the Dying Introduction
22. New American Bible (NASB) John 13:35
21
23. Declaration on Euthanasia Section 2-Franjo Cardinal Seper and Approved by Pope John Paul II (1980)
24. ERD Part 5-Issues and Care for the Dying Introduction
25. ERD Part 5-Issues and Care for the Dying Section 57
26. This definition of ordinary and proportionate care will be applied to the case of Emilio Gonzalez.
27. Terri’s Network is an organization dedicated to an depth recall of the life, suffering, legal battle, and death of Terri Schiavo. This group wants to ensure that what happened to Terri does not continue happening. Their vision and mission: Where There's Life, There's Hope - Promoting a Culture of Life by embracing the true meaning of compassion by opposing the practice of imposed death. The mission of the Terri Schiavo Life & Hope Network is to develop a national network of resources and support for the medically-dependent, persons with disabilities and the incapacitated who are in or potentially facing life-threatening situations.
28. D. Barnard in his article The physician as priest, revisited discusses that doctors must have “moral expertise” because they are handling sick patients who need help physically but also existentially.
29. ERD Part 5-Issues and Care for the Dying Section 59
30. ERD Part 5-Issues and Care for the Dying Section 61
31. Pope John Paul II in Evangelium Vitae on how precious a human life is no matter what stage or condition it is in. Life begins at conception and ends at natural death.
32. New American Bible (NASB) 1 John 3: 1-2
22
CHAPTER THREE
The Texas Advance Directives Act of 1999
The last chapter was concerned with Catholic beliefs on death and dying. The aim
of this chapter is to clarify the legal and political aspects of end of life care. The state of
Texas has set a national precedent in its laws pertaining to end of life care, enacting one
specific law as a model for other states to follow: the Texas Advance Directives Act of
1999 (TADA). This law sets guidelines for how to handle complex end of life disputes in a medical facility. If medical professionals follow the steps laid out in TADA they are protected by law from being sued by patients and their families. Robert L. Fine, M.D., who was involved in the writing of TADA, lays out these guidelines for fellow physicians:
Advance directives in Texas clearly recognize that patients may use a directive (living will) to reject or request treatment in the face of terminal or irreversible illness. Surrogates acting on behalf of incompetent patients may do the same. However, not all requests are necessarily granted. If there is a request for treatment that the treatment team feels is medically futile or pointless, an ethics consultation may be requested. Under the new law, the following process must occur if the treatment team and institution wish to take full advantage of the provisions of the law creating a legal safe harbor for them. These provisions are as follows: 1. The family must be given written information concerning hospital policy on the ethics consultation process. 2. The family must be given 48 hours’ notice and be invited to participate in the ethics consultation process. 3. The ethics consultation process must provide a written report to the family of the findings of the ethics review process. 4. If the ethics consultation process fails to resolve the dispute, the hospital, working with the family, must try to arrange transfer to another provider physician and institution who are willing to give the treatment requested by the family and refused by the current treatment team.
23 5. If after 10 days, no such provider can be found, the hospital and physician may unilaterally withhold or withdraw the therapy that has been determined to be futile. 6. The party who disagrees may appeal to the relevant state court and ask the judge to grant an extension of time before treatment is withdrawn. This extension is to be granted only if the judge determines that there is a reasonable likelihood of finding a willing provider of the disputed treatment if more time is granted.
If either the family does not seek an extension or the judge fails to grant one, futile treatment may be unilaterally withdrawn by the treatment team with immunity from civil or criminal prosecution. (This is the “legal safe harbor” for physicians, institutions, and ethics committees, the first of its kind in the country)” (Texas Health and Safety Code Section 166, 1999).
This is a summary of the Texas Advance Directives Act. The law itself consists of
60 pages of conditions and stipulations that guide matters such as establishing the power of attorney, when to perform CPR, and the responsibilities of everyone involved in a dying patient’s case. This law was written to protect physicians and healthcare providers from litigation as well as provide a set process for medical providers to follow in this difficult time. In the following chapters, laws such as TADA will be investigated further to gauge the protection of the sanctity of life of the dying, an imperative stressed by the
Catholic Church. But first it is important to see how this law came about and look at the cases that sparked its creation.
To get an idea of the complexity of this topic, the 1989 case of Catherine Gilgunn
will be addressed. In May 1989, 71-year-old Catherine Gilgunn of Massachusetts fell in
her home and injured her left hip. In addition to this hip injury, Catherine had diabetes,
heart disease, Parkinson’s disease, and breast cancer. She had just suffered a stroke and
was recently hospitalized for two grand mal seizures that were uncontrollable by
physicians. Catherine was subsequently in a coma and her daughter, Joan, was left to be
her surrogate in terms of medical needs. Catherine had told Joan she wanted everything
24 done to keep her alive. Even after knowing the wishes of Catherine, the attending physicians wrote a Do Not Resuscitate (DNR) order because the hospital’s Optimum
Care Committee (OCC) deemed any form of revival to be futile. Catherine was then weaned off of the ventilator because the doctors knew she was going to die from the many chronic diseases and disorders so ventilation was pointless. Three days later, on
August 10, 1989, Catherine Gilgunn died.
Joan Gilgunn sued the physicians and the hospital for neglect and infliction of emotional distress. The court ruled in favor of the physicians and the hospital. They stated that Catherine’s wish to be resuscitated was futile. But this was not the real issue in this case. The issue was that the hospital did not have any procedures and protocols regarding resolution of the dispute between hospital and family concerning end of life care decisions (Karen Trotochaud, 2006).
Cases like Catherine Gilgunn’s prompted the enactment of a law that would propose guidelines for similarly tough situations. In this case, the physicians made
Catherine DNR against her wishes and removed her from her ventilator with no ability to be resuscitated if she needed to be because she was DNR. While this may have been the right thing to do since it was apparent that this treatment was futile, Catherine’s wishes were not honored in this process. In this case, the doctor thought one thing and the family thought another, and, because of this unregulated dispute, the patient lost autonomy and the family saw this as a loss of dignity. Medicine is not about doing everything possible to save the patient; it is about doing everything within reason to save the patient. This is just one example of a battle between family and physician about what futile care is and
25 what is within the limits of healing. This era had enough of these controversies that
something had to be done to not only protect doctors but also the dignity of patients.
These difficult end of life cases brought into the forefront of medicine the idea that
because of the increase in technology, patients who would otherwise have died could be
temporarily sustained. Doctors are now working on the balance of how far they can
stretch medicine to save lives and when to allow a patient to die. Multiple court battles
ensued over medical futility and the removal of treatment. Courts said one thing,
physicians did another, and there were no laws to regulate this difference. Moreover, the
decisions made by a physician could result in significant and costly legal disputes.
In early 1999, the American Medical Association (AMA) tried to remediate this
problem by posting some loose guidelines on how to handle cases of medical futility. The
AMA’s guidelines said the same thing as today’s law but there were no legal ramifications for physicians who did not abide by these rules because they were not binding law. Later that year, Texas decided to make these rules into actual law. This law was put into place to resolve any disputes between family and physician concerning death. “When there is a request for treatment that the physician feels is inappropriate, an ethics consultation may be requested. If the guidelines of the statute are followed, the law creates a legal safe harbor for both physicians and hospitals by granting immunity from civil and criminal liability” (Robert Fine, 2003).
TADA cleaned up the chaos a bit and provided some guidance for physicians.
However, TADA did not solve all of the problems regarding end of life care decisions.
Not everybody agreed with this law and its stipulations. A recent Texas case presented
26 just this problem. The 2007 case of 16-month-old Emilio Gonzalez brought national
attention to this particular Texas law.
Emilio Gonzalez was in the Pediatric ICU in Austin, TX. He was deaf, blind, and
dying of Leigh’s Disease. This disease had destroyed his central nervous system,
inhibiting his ability to breathe, swallow, and move, forcing the toddler to depend on a
respirator. The family knew that Emilio’s disease was eventually fatal, but they still wanted to do everything possible for their son. On many occasions physicians advised the mother, Catarina Gonzalez, that it would be best to discontinue Emilio’s treatment but
each time she refused. The hospital’s ethics committee deemed Emilio’s care futile,
giving Emilio and his family the ten day window to move to another facility. Emilio’s
mother worked with lawyers to keep her son alive. "I believe there is a hospital that is
going to accept my son," said Gonzales following the brief hearing. "I just want to spend
time with my son…I want to let him die naturally without someone coming up and
saying we're going to cut off on a certain day." Legal authorities for the Texas hospital
released statements saying “the child’s condition is deteriorating although he has not met
the criteria to be declared brain dead.” The hospital and its ethics committee believed that
continuing treatment would cause pain. The hospital claimed that “this aggressive
treatment plan was an assault on human dignity,” but the family still insisted on
prolonging treatment33 (Sylvia Moreno and Mark Mostert, 2007). Thirty one hospitals
nationwide refused to continue the care of Emilio. Still, the courts ruled in favor of
Catarina Gonzalez by issuing a restraining order preventing the hospital from
withholding Emilio’s care. The hospital could then do nothing but continue the treatment,
despite the ruling of its ethics committee. Three months after the initial decision to
27 remove treatment, Emilio died from Leigh’s disease (Sylvia Moreno, 2007).
This case demonstrates the difficulty of enforcing a law like TADA. It is also an example of the kinds of battles that will inevitably ensue between families and physicians. In this case, the physicians and hospital wished to withdraw treatment via a respirator to a patient who still had brain function. The ethics committee argued that this would cause pain to the young patient, yet the mother wanted to let the disease take its course, with all possible medical assistance for her son. Interestingly enough, the
Catholic Bishop of Austin took the same stance as the hospital’s ethics committee on this case. This caused a whole new dimension to emerge in this battle over young Emilio.
Another aspect of this case to consider was that Emilio’s mother was a 23 year old single mother who was most likely not paying for Emilio’s treatment. Since she was not burdened by the debt, it could be suspected that she may have made a different decision about prolonging her son’s treatment had she been financially invested. This case will be discussed further in the following chapters in an attempt to determine who really had the boy’s best interest at heart.
Robert L. Fine works on research involving the value of the Texas Advance
Directive Act. The research by Fine indicated that:
This legally sanctioned process gives physicians more comfort in confronting possible futile-treatment situations. Explicit futility consultations have increased 67%. This suggests that a previously less visible process has been converted into an explicit process, which provides safeguards and accountability for decisions. Our experience suggests that when physicians have a legally approved process to appeal to, they are willing to use it in an open fashion. (Robert Fine, 2003)
This is progress. Communication, the backbone of medicine, was lacking when physicians were too scared to address life ending decisions for the fear of being sued.
Now that physicians are safe from malpractice lawsuits, they are more willing to talk
28 with the families and patients about futile care whereas before, topics such as removal of
treatment were feared among providers.
Dr. Robert Fine also collected data on the use of TADA in Texas. Fine “collected
five years’ worth of information from eleven large hospitals in Texas and two years’
worth of data from five other large hospitals in the state.” According to this data, the
hospitals surveyed held 2,922 ethics committee consultations, 974 of these cases were
medical futility cases. Out of those 974 medical futility consultations, the hospital’s
ethics committee issued 65 letters that stated agreement with the attending physicians that
the proposed treatment should be withdrawn after the patient had exhausted the 10 day
transfer window. The hospitals withdrew treatment in only 27 of the 65 cases, while 22
patients died receiving treatment as they awaited transfers. The remaining 16 cases did
not have a listed outcome (Robert Fine, 2000).
Dr. Robert Fine has also done follow up studies with Texas hospitals to gauge the
effectiveness of TADA. After analyzing the results from this study, Robert Fine said:
I believe the Texas law has helped to foster a much-needed conceptual and temporal framework for facing medical futility disputes that is not available elsewhere. I believe the law fosters the best interests of patients in extraordinarily difficult cases, and supports the moral integrity of physicians, nurses, and all who work in medical institutions for the benefit of the most vulnerable patients of all. Thus, the ethical foundation for the law is sound. Although it can clearly be improved, its benefits outweigh any detriments, and other states should develop similar laws with improvements based on the experience in Texas (Robert Fine, 2009).
Dr. Fine makes it known that without the Texas Advance Directive Acts, end of life care in Texas would be in a dire situation. TADA still has issues that need to be addressed, but it does provide some guidance to this very difficult and controversial topic. (Robert Fine)
29 The case of Emilio Gonzales provides us with a behind the scenes look at TADA
in action. A person rarely see this law put into action unless it has to do with his own
dying family member or they see the controversial side of these cases come up on the
evening news. What the nation saw was one young mother against one giant hospital.
From the eyes of the viewer, TADA was killing this baby boy and there was nothing
anyone could do about it. The law had spoken.
Elizabeth Graham, director of Texas Right to Life commented in response to
Emilio’s case. "Texas has the worst law in the country because the families have no
recourse," "In Texas, doctors only provide treatment for ten days, and if there's no
transfer, they pull the plug" (Liz Townsend, 2007). George W. Bush, then Governor of
Texas, signed TADA into action and at the time of its beginning stages, this law seemed
like it would work well. Even anti-abortion and pro-life groups supported this law. At the
time of the enactment, no one involved knew that the ten day window to transfer would
not be enough (Sylvia Moreno, 2007). This would not be found out until TADA was later put into action in cases like Emilio’s. It is still hard to say what length of transfer window would be long enough. Because of difficult cases like the ones stated above, government officials have been stepping forward and offering their opinion on these challenging circumstances. “Catarina Gonzales's lead attorney, Jerri Ward, along with Texas Right to
Life and other groups, has asked state lawmakers currently in session to change the law so life-sustaining care is provided, with no deadline, until a patient transfer is made. ‘The benefit of treatment for this child (Emilio) is continued life,’ Ward said. ‘Yes, he (Emilio) will never be a normal little boy, but there are plenty of people out there who are not normal but continue life and enjoy it to the level they are capable of’” (Sylvia Moreno,
30 2007). Catarina managed to circumvent the law allowing her son to die as naturally as
possible instead of dying by the removal of treatment by a physician. But once again, was
this act by the mother what was actually more dignifying for her son? The following
chapters will discuss this in further detail.
This topic of medical futility is a difficult one to tackle, especially in Texas where there is a law that in many ways complicates this situation. This law was designed to
protect the patients and although it is a good foundation, it still comes with issues and
controversies. Christian doctors should always have the dignity of the patient in mind, but
things do not always turn out this way. Medical futility cases can be particularly
challenging for people of faith. Christian doctors can be put in a tough position when
their patient’s dying wishes compromise their own beliefs. As stated earlier, combining
death, medicine, and religion are difficult in and of themselves but to make matters
worse, government, laws, and policies can tend to add more chaos than order to this
already difficult situation. Adding to the mix a doctor’s personal beliefs as well as the
beliefs of the patient makes for a nearly unconquerable task. The following chapters
discuss the difficulties behind combining faith and politics in end of life care decisions in
a Catholic hospital setting.
31 Endnotes
33. Both the newspaper articles discussing the case of Emilio Gonzalez and the actual court case entitled Catarina Gonzales v. Seton Family of Hospitals from the United States Western District Court of Texas were used to gather information on this case. Facts from the newspapers were cross checked with the court case.
32
CHAPTER FOUR
The Practical Application of Catholic Doctrine Within The Hospital Walls
The previous two chapters set up the background for the Catholic belief system as well as Texas end of life care policies. This chapter will evaluate these concepts and assess their compatibility side by side. The relationship between the Catholic Church and modern medicine will be addressed by applying the Catholic stance on specific patient cases. Finally, the similarities and differences between Catholic doctrine and laws/policies that occur within hospital walls will be showcased as well as defined
Where When When a Power to Protection Document document document is person enforce offered by put into gets used disagrees contents document action authority with this of document’s document decision ERDs Infallible Voluntarily Simply do Not No Users should documents used by not follow powerful protection be Catholic that Bishops Catholic this unless from or agree with used to patients, document you government Catholic write the physicians, believe doctrine ERDs and hospitals Catholic doctrine is true and binding
TADA Government Used in Decision is This is This law Use once situations in permanent law provides a there is a Texas when after the 10 legal safe disagreement the physician day transfer harbor for between a and window physicians physician and patient/family if they a patient over cannot follow this the course of resolve law treatment. disagreement
33 The ERDs and TADA have clear differences, as can be seen in the above chart, but these differences do not necessarily make for disagreement. The first of a few differences to be addressed is the authority that brought these documents into ones that govern moral decision making. The ERDs get their authority to govern the lives of
Catholic believers by the authority invested in their Catholic Bishops. As mentioned earlier, Catholics believe in both the Bible (Scripture) and other divinely inspired supporting documents accumulated over the years (Tradition). The ERDs are not in themselves part of Sacred Tradition but Bishops would have written the ERDs using documents of Sacred Tradition such as papal encyclicals. On the other hand, TADA was given its authority by the state that binds members of that state to the provisions mentioned within this law. If one does not follow the rule of TADA, negative legal repercussion can result. The fact that TADA is a law gives it a very highly respected authority amongst law abiding citizens.
Another difference between TADA and the ERDs can be seen in the ways these documents are used and put into practice. The ERDs are a voluntary document. No one is going to force someone to use these documents if the situation permits. Catholics have to opt in to abiding by these rules out of fear for what may happen in their afterlife if they did not follow the ERDS or because their devotion to their Lord and faith prompts them to do so. The ERDs should be followed by every Catholic patient, physician, and hospital taking into consideration that each of these members abides by the teachings of the
Catholic Church. As can be accurately assumed, the ERDs are not used in every situation that could potentially require their guidance. TADA on the other hand is binding by law but not by fear of the spiritual unknown as was seen with the ERDs. TADA can
34 potentially be used in every situation where a physician and a patient/family disagree on the course of treatment and they cannot resolve this issue. If this law is not followed then the physicians involved will be legally liable for any wrongdoing because they did not follow the hospital’s set procedure. Non-Catholic Christians and non-Christians as well may still agree with what the ERDs have to say but they are not bound to Catholic doctrine and the entirety of its contents, as are Catholics.
Differences can also be seen when people disagree with the content of these documents. First, if someone disagrees with what is written in the ERDs, but is not
Catholic, then nothing is going to happen if he disagrees with what is said. It may be that by rejecting these documents one is distancing himself from God but this cannot be determined as of now. If a Catholic disagrees with the content of the ERDs then he should discuss this issue with a priest, nun, or Catholic theologian to better understand the meaning behind what is said within the document. Even though this document is not part of Sacred Tradition, the documents that the ERDs are based upon are infallible and therefore should be fully followed by every baptized Catholic. Disobeying the doctrine upon which the ERDs are based is a sin, and if this sin is committed then to a Catholic it would need to be confessed to a priest in order to be forgiven. Contrary to this, if someone disagrees with what TADA says then he can make an appeal to the courts to have the law struck down taking into consideration these new requests. The Texas
Hospital Association has already suggested revisions to TADA. As can be seen in the previous chapters, there are differing views on end of life issues. In situations like the ones discussed here it can be hard to reconcile these differences amongst parties. The passing of TADA was a good first attempt at a law that would regulate end of life care
35 disputes but it is evident that the work started by the passing of TADA is not finished. In early 2013, different groups including the Texas Hospital Association (THA), Right to
Life groups, hospitals, hospice facilities, nursing homes, and lawyers discussed potential revisions to the Texas Advance Directives Act. The goal was to make this law clearer to patients and their families, empower them to be in charge of their own end of life decisions, and protect the dignity of everyone involved. The Texas Hospital
Association’s suggested revisions to TADA include:
1. Clarifying the types of patients to whom the law applies, making it clear that treatment cannot be withdrawn for patients with irreversible chronic but non- terminal conditions, such as diabetes or chronic obstructive pulmonary disease. 2. Ensuring that all patients are provided with artificial nutrition and hydration until they become harmful to the patient or until the natural death process has begun. 3. Establishing clear, objective criteria by which ethics committees can judge a physician’s decision to withdraw treatment. These criteria protect providers from being required to harm their patients with treatments that do not correspond to the real needs of the patient. 4. Clarifying the definition of “medically ineffective” treatment to clearly explain that resuscitation is unlikely to be successful and that the ineffective medical intervention could be traumatic and painful for the dying patient. 5. Establishing a clear, well-defined multi-stage process for a physician to implement a Do Not Attempt to Resuscitate order; the process keeps the patient/family informed and provides a mechanism to disagree, seek a second opinion, request a medical ethics review and seek legal intervention through the courts if issues cannot be resolved. 6. Ensuring more compassionate communication among physicians, caregivers and family members/loved ones throughout the dispute resolution process. If a patient advocate is selected, he is to work with the family and make sure that everyone is informed of their options and then take appropriate actions.
The goal for this set of revisions is aimed at honoring patients’ wishes as well as providing care to patients that is in their best interest. Revision number two discussed above, concerning nutrition and hydration, addresses one of the main concerns that the
Catholic community has with TADA. These revisions made sure that the treatment that was beneficial to a patient was continued and treatment that was burdensome was
36 stopped. This is strictly in line with the Principle of Double Effect discussed in Chapter
One. These revisions are reflected in both Senate Bill 303 and House Bill 1444 although
neither has become law (Texas Hospital Association).
In an end of life care case where both the ERDs and TADA can be used, only one
document is going to protect everyone from earthly punishment. By simply following the
ERDs and rejecting TADA a person has no protection from the government or civil
litigation. By rejecting TADA this individual is in turn rejecting his legal safe harbor and
has exposed himself to severe legal issues. Physicians used to fear lawsuits during end of
life disputes but TADA protects them from this while the ERDs do not. By following the
ERDs one is assured that the dignity of each person will be upheld. Preserving human
dignity should be taken into account in the use of TADA but this is not necessarily the
case. A physician who follows the law to protect himself from harm and lawsuits while rejecting dignity of each human life may not always be doing the right and moral thing.
An example of the conflict between the Catholic Church and today’s medicine is the care of an anencephalic baby. According to the CDC, an anencephalic baby is a baby born with a birth defect that results in partial or complete absence of the skull and brain.
There is no skin or bone covering the part of the brain that is present. Most babies born with this condition do not survive the newborn period but there are cases where the baby can survive up to a few weeks or months (Center for Disease Control). As one can see, this is a very difficult and sensitive situation. Some people would say that such a baby has no higher functioning and is so debilitated that it is no longer a human person.
Another perspective would say that human life, at all stages, no matter how compromised
37 is still a human person. Both of these points of view will be explored further in the following sections.
The Ethical and Religious Directives state that basic needs such as food and water may not be withheld from any patient. These basic needs should be provided at all times unless the burdens of this treatment outweigh the benefits. In the case of an anencephalic baby, although he may only live for a few minutes or hours, the Catholic Church deems it right and moral to provide this child with basic human rights (USCCB, 2009). The
Catholic Church’s perspective is that life begins at conception and ends at natural death.
In this context, natural is defined as the lack of prematurely ending someone’s life before his body gives out or the disease takes its course. A death from starvation or dehydration because of the removal of nutrition is not a natural death; therefore, neglecting to give basic needs to an anencephalic baby is against Catholic teaching. The goal, as long as the benefits outweigh the burdens, is to maintain the dignity of the life of all persons whether they are new to the world or on their way out of this world.
It is obvious that not everyone believes Catholic teachings. Even Catholics struggle to believe in a manner consistent with Catholic doctrine on some issues. With increasing technology, parents are finding out earlier and earlier in pregnancy about any physical anomalies of their baby. Some parents will immediately abort the baby if they find out their child has a physical abnormality such as anencephaly. A child with this deformity is traumatizing to a parent as well as healthcare providers. In the case of anencephaly, doctors may perform late term abortions or induce early labor in the mother so she does not have to carry the fetus to term34 (Orlando Women’s Center). An abortion may be recommended in order to shield the parents from the tragic event of giving birth
38 at full term and knowing the baby will die within minutes or hours. As anencephalic babies have no cognitive function, it is acceptable in the minds of some individuals to perform an abortion (Father Benedict Ashley, 1998). The Catholic Church would deem such abortion to be morally objectionable but others may justify an abortion because this infant would live such a brief life that prolonging a pregnancy in order to give birth to a severely deformed baby does not make sense. Many people believe that because anencephalic babies cannot think, do not have higher functioning, are severely disabled, and cannot give back to society in any way that they have no right to life.
As can be seen with the scenario of an anencephalic baby, one of the biggest and most prominent differences between the Catholic Church and secular medicine is what constitutes a human person at the beginning and end of life. Anencephaly is interesting because it is an end of life issue occurring at the beginning of life. Catholics believe that life ends when God takes it away. Natural death, aided by no human hands, is the only
Catholic way to conclude a life. Historically, someone is dead when his heart stops beating, he stops breathing, and he loses all brain activity including the brainstem
(Medical Dictionary). The Catholic Church agrees with this statement of clinical death.
When someone’s heart is no longer beating, it means that life has ceased. According to the National Catholic Bioethics Center (NCBC), brain death occurs when both higher and lower functioning has stopped. Someone with a brain injury and damage to only their higher functioning is not dead (Father Tad Pacholczyk, 2005). Anencephalic babies may have a brainstem that allows the heart to beat and lungs to breathe so, therefore, according to NCBC and the definition of clinical death stated above, an anencephalic baby is still alive (Georgetown University). There may be no clear-cut answer to the
39 question of when life ends for non-Catholic thinkers, which is why it is such a difficult and controversial topic. What can be concluded is that much of the world’s view on life and death does differ from the Catholic belief of “from conception to natural death.”
With this said, Catholics do not believe in extending life for the sake of extending life alone. They look at the benefit of the treatment over the burden, the quality of life of the patient, and the wishes of the patient.
If this case were not difficult enough, it becomes even more complex when laws and policies are put into action such as the aforementioned Texas Advance Directives Act
(TADA). If an anencephalic baby were born in a Texas hospital and there were to be a disagreement between the physician and family members on the treatment plan for the baby, TADA would play into the outcome of the baby. If the baby survived past the first hours of life, an ethics committee might be contacted about this case. An ethics committee would certainly be contacted if there were a disagreement between the physician and parents regarding what to do with the baby. An ethics committee could also be contacted if any member of the medical staff disagrees with the physician’s treatment plan for the patient. This ethics committee could decide that this baby deserves a chance at life, no matter how short, and could ask that the baby be kept comfortable with basic needs for the remainder of its life. Conversely, the ethics committee could determine that it is unnecessary to provide the baby with any treatment because treatment would be futile since the baby would die shortly regardless of what is done. If the family members disagree with this decision, they could look into finding another hospital to take the baby in transfer. The family would have ten days to transfer the baby’s care to another facility or else treatment would cease and the baby would not be given the
40 deemed futile treatment. In this scenario, the ethics committee would believe that this child’s care is excessive and that it would die shortly. To complicate matters, there have been cases of anencephalic babies living for months or years with this disorder without extreme treatment. There was a case of an anencephalic baby boy in Colorado who lived for three years after birth (Jaywon Choe, 2012). From a Catholic’s perspective, this one case is enough to justify treating all of these children with the same dignity and respect as any other person.
TADA allows ethics committees to govern the withholding of treatment to an individual patient if it is deemed to be futile or non-beneficial. If an ethics committee deems further chemotherapy for a cancer patient to be futile, then the doctor could withdraw care unless a transfer is made to another facility. TADA allows the ethics committee to provide a legal safe harbor for the physician to avoid legal repercussions if chemotherapy drugs are not given. If an ethics committee says that a respirator is pointless for an anencephalic baby, then it allows the respirator to be unplugged. An ethics committee could also deem tube feeding to be futile so this could conceivably be withheld as well. The Baby Doe Law of 1984 protects a handicapped child from being denied treatment because of his disability even if this goes against the wishes of the parents. This law is effective if people believe an anencephalic baby is a human person because the Baby Doe Law protects human life. If someone thinks that an anencephalic baby is not a human life then he can still deny the baby’s treatment. He would not be denying the baby treatment based on disability but instead he is denying treatment based on personhood and whether or not he thought this baby was a person (Jack Resnik). The
Catholic Church thinks that even the most disabled are human persons and deserve basic
41 human needs and this is the crux of the issue: the definition of a human person. Pope
John Paul II had this to say on the definition of a human person.
“The human person, no matter what his condition, is a being of moral worth, the subject of inviolable rights that are to be recognized and respected by others, including the inviolable right of innocent human persons to life, not to be intentionally killed, and the right of children to be born in and through the conjugal act” (William May, 2004).
Catholic patients, families, doctors, and hospitals have doctrine that guides their
views regarding management of an anencephalic baby. This set and steady doctrine
provides direction for such difficult cases such as an anencephalic baby. The difficulty
lies in the fact that even people who are Catholic have views that span the entire
spectrum. It makes it difficult to have a protocol for complex cases when interested parties believe different things should be done for the patient. The simplest case occurs when Catholic parents give birth to an anencephalic child in a Catholic hospital with
Catholic doctors. There is no doubt that if these are devout Catholics, this baby would be treated with the utmost dignity and respect. This baby would be given the chance to live his life as long as he could as long as he was not suffering from his proposed treatment such as a feeding tube. It is more complicated when, for example, the doctor is not
Catholic, when the ethics committee is made up of diverse beliefs, or the hospital is a public hospital. This is not to say that secular hospitals would not treat the patient with respect or dignity but their definition of dignity and human existence may differ. As one can see, many factors contribute to a patient’s management inside hospital walls.
42
Figure 2: Baby with Anencephaly (Dimitri Agamanolis, 2012)
The conflict over an anencephalic baby could be addressed by TADA and the methodology would be similar to the steps taken with someone in a vegetative state like
Terri Schiavo. If Terri were in a Texas hospital, she might have fallen under the rule of the Texas Advance Directives Act. This law would be enacted if there were a disagreement between the caretakers and Terri’s family. In the Schiavo case there was a disagreement. TADA would state that if an ethics committee found that Terri’s future treatment were futile or pointless because of her vegetative condition then her family would have ten days to transfer her care or her food, water, and other treatment could be stopped. Herein lies the controversy. “While medically assisted nutrition and hydration
43 are not morally obligatory in certain cases, these forms of basic care should in principle be provided to all patients who need them, including patients diagnosed as being in a
“persistent vegetative state”35 (USCCB, 2009, pg 30). A clear disagreement is seen when
Texas physicians could force removal of nutrition and hydration while Catholics will likely provide this need at all times unless the stated exceptions are satisfied. If the case of Terri Schiavo happened within Texas borders her outcome would likely have been similar although there may not have been a 15-year battle to remove her feeding tube.
Terri’s care would have been taken to an ethics committee and it could have deemed her care futile and her feeding tube could have been withdrawn after ten days unless there was a transfer of her care. In the care of a devoutly Catholic hospital, Terri would have been given food and water until the food and water created a burden on Terri or her family. Burdens placed on Terri’s family might include financial burdens as well as the emotional toll of taking care of someone who is in a vegetative state. Also, the quality of
Terri’s life has to be taken into consideration. To some people, someone who spends 15 years in a coma, in the same position, is not a human person. Such individuals cannot give back to society and are only taking time, money, and attention from the society without a hopeful outcome. The contrary belief would be that this same individual, in a coma for 15 years, is still a person. Others would think that 15 years in a coma would result in a loss of dignity. These issues are addressed in the ERDs and must be considered when managing an end of life care decision.
The case of Karen Quinlan is different from the other cases because the patient and her family were openly devout Catholics themselves. Karen Quinlan collapsed after mixing alcohol and unknown drugs at a college party in 1975. She stopped breathing and
44 ended up in a persistent vegetative state at the age of 22. She was initially taken to a
public hospital and was transferred to a Catholic hospital a few days later. Karen was fed
by a feeding tube and was on a respirator. After consulting their trusted parish priests, the
family determined that the respirator was extraordinary and not ordinary care and wanted
it removed. The feeding tube was kept in place. The hospital refused to remove her
respirator out of fear that this would be a homicide. It was not until the Quinlan’s
obtained a court order to protect the hospital and physicians that the respirator was turned
off. Surprisingly, Karen was able to breathe on her own after the respirator was removed.
She lived for nine more years with the feeding tube providing her nutrition until she later died from pneumonia (NCLL). Religious officials and the family deemed that the respirator was not an ordinary or natural treatment option; therefore, it was removed.
They did not try to prolong life at all costs and cause suffering but tried to eliminate suffering caused by the disease. If the feeding tube had been removed along with the respirator, Karen’s family would have violated the ERDs unless the feeding treatments were causing more of a burden. It is critical to remember that nutrition and hydration are ordinary care measures and should be provided to all patients unless the burdens outweigh the benefits. The case of Karen Quinlan is interesting in that the hospital wanted to continue futile treatment while the family wanted to discontinue the respiratory treatment after discussing this decision with a Catholic priest. Had a law similar to
TADA been around, this case may have turned out differently. Although the ERDs were not written yet, the family chose to follow established Catholic doctrine while the hospital requested legal security for following through with the family’s wishes.
Depending on how the ethics committee would have ruled, a law such as TADA may
45 have allowed the Quinlan’s to remove the respirator without the challenge of obtaining a court order to protect the physicians.
If young Emilio Gonzalez, discussed in the previous chapter, had been taken to a
Catholic hospital as opposed to a public Texas hospital, the treatment of Emilio may have been different. As mentioned earlier, the Bishop of Austin approved the removal of treatment for Emilio but because of the restraining order placed on the hospital neither the physicians nor the Bishop’s requests were honored. Emilio was at Children’s Hospital in Austin, which had no religious affiliation. Emilio’s mother found a way around the law and was able to get a restraining order from the county judge against Children’s Hospital and the physicians. This prevented the hospital from removing the respirator and allowed
Emilio to die as naturally as he could. This restraining order, preventing the physician per the ethics committee to withdraw treatment through TADA, was in line with Catholic teaching. Ideally, a Catholic hospital’s ethics committee would not decide to forego treatment unless the burdens associated with the treatments were excessive or the dignity of the patient was compromised. Unless a Catholic serves on an ethics committee at a public hospital, the ethics committee could potentially make a decision inconsistent with
Catholic doctrine. Ideally in a Catholic hospital, the Catholic way of treatment will be executed. This is only held true if the Catholics on the ethics committee have a correct understanding of Catholic teaching. Even though TADA was issued to create a way of dealing with conflicts about futile care, there are still disagreements between parties.
Religious doctrine can potentially interrupt TADA’s function making end of life care an even more complicated situation.
46 Bishop Aymond of Austin stated in his response to the case of Emilio Gonzalez
that “the Catholic Church would teach if there is no possibility of recovery, that
extraordinary means can be withdrawn, and it is not taking the life of a person, but simply
allowing them to die naturally and with dignity”36 (CVSTOS FIDEI, 2004). This
statement caused an uproar in the Catholic and medical communities. The reason this was
so troubling, specifically to Catholic observers, was that this request by Aymond went
against some of the core values that Catholics believe in regard to end of life care.
Catholics believe one should never remove any treatment unless it is causing more of a
burden than a benefit. In this case, it was assumed that Emilio potentially could be in pain
but no sources confirmed the great burden that was suspected by the physicians. (Sylvia
Moreno) The Catechism of the Catholic Church (2269) states, “the fifth commandment
forbids doing anything with the intention of indirectly bringing about a person's death.
The moral law prohibits exposing someone to mortal danger without grave reason, as well as refusing assistance to a person in danger.”37 According to the Catholic Church, if
Emilio was not suffering then the removal of his treatment was done with the intent to
end his life. The Catechism also makes a special point in section 2276 that those who are
handicapped and debilitated deserve special care in order to allow them to live as normal
of a life as possible. In ending Emilio’s life, this was not allowing him to live a life as normally as he could.38 A respirator may not be what most people consider normal but for
Emilio, it was his normal.
This controversy brings up the conversation about what is ordinary and what is extraordinary care. One is never to withdrawal ordinary care such as food and water as was the case in the death of Terri Schiavo. In the removal of Emilio’s treatment, the
47 Bishop of Austin stated that comfort measures such as pain medications, food, and water
would be given to the patient, however, as a result of the removal of the respirator,
Emilio would die. Bishop Aymond also wrote, “Numerous physicians have stated that
Emilio’s condition is irreversible and will result in his death. There is also great concern
that continued extraordinary treatment will only result in greater pain for Emilio, without
curing or improving the condition from which he suffers” (Bishop Gregory Aymond,
2007). The Catholic Church would say that Emilio may die by his disease but the disease
should still be treated no matter how debilitated or close to death he is as long as the
treatment is not burdensome. Bishop Aymond also stated that continuing treatment would
cause the child to suffer. If Emilio was suffering because of the treatment, then it would
absolutely be morally acceptable and in line with Catholic doctrine to remove this
treatment. In Emilio’s case it was not clear if he was suffering or not. Emilio’s mother
stated that he made funny faces and squeezed her hand while the medical providers
thought these “funny faces” were grimaces of pain. Emilio’s mother stated that he was on
enough morphine that he should not be in pain but the doctors thought otherwise
(Elizabeth Cohen, 2007). If it were clear that the treatment was causing more of a burden
than a benefit on young Emilio then it would be justifiable to discontinue this treatment.
As long as Emilio’s caretakers are working to make his short life as normal as possible
then they are upholding the dignity and worth that Emilio deserves. Remember that the
Texas Right to Life group said, “Even though this [person] may not be normal, who is to say what normal is?” For Emilio and his mother, Catarina, this current state is as normal
as Emilio will get and she has come to terms with this. Most mothers never want to see
her child suffer and if there were clear indication that he was suffering, Catarina would
48 have tried to eliminate her son’s pain however she could. A radical decision to forgo treatment of her son was not an acceptable option for her. The son she knew and loved was still there. His brain functioned, albeit not normally, but it functioned. Emilio’s body was failing but his personhood was not (Sister Patricia Talone, 2009).
Figure 3: Baby Emilio with his mother shortly before his death (Sylvia Moreno, 2007)
This case of Emilio brings up another important issue. This case illustrates a disagreement between two parties in the Catholic Church. Bishop Aymond felt that he was following the doctrine of the Catholic Church by relieving Emilio’s suffering. Right to Life groups within the Catholic Church believed that the mother was following the doctrine of the Catholic Church by prolonging Emilio’s life-sustaining treatment. This case demonstrates that even amongst Catholics there is a wide range of beliefs. There may still be disagreement amongst Catholics even with Catholic doctrine such as the
Catechism and the ERDs to try and regulate this chaos.
Through the evidence from the above cases, it can be determined that the Texas
Advance Directives Act has added some order to the conflicts in the end of life care process within a hospital. It can also be determined that the Ethical and Religious
Directives are bringing some order out of chaos within the Catholic Church and
49 providing a guide for people who have questions regarding end of life care issues. It was hypothesized that the Catholic Church and the medical field would be more in conflict than they actually are. There seems to be more differences amongst the documents than disagreements. TADA created a more uniform set of protocols for hospitals to follow in
terms of end of life care if a disagreement arises between parties. The Ethical and
Religious Directives bring guidance in making proper decisions at the end of life. The
ERDs are used to guide beginning and end of life care consistent with the moral traditions of the Catholic Church. When TADA governs all Texas hospitals, at times, it can be hard for Catholics to be consistent with the ERDs and other Catholic doctrine
when TADA and an ethics committee seem so overpowering. A potential for
disagreement can be seen when Texas physicians could conceivably force removal of
nutrition and hydration through the law of TADA while Catholics will provide this need
at all times unless this treatment is burdensome. The situations discussed above provide examples of how difficult cases could be decided in varying medical settings. As mentioned earlier, combining medicine and religion is challenging but it becomes even more difficult when adding in laws and doctrine as was illustrated in this chapter.
Although we would like a clear cut answer to this dilemma there still really is no answer.
Every person has his own story and at the end of his life he has his own set of desires, wishes, and challenges. Every case discussed above is unique and could benefit from the use of TADA and the ERDs. It is difficult to say that one of these stances is better than the other. What can be said is that as long as everyone involved is keeping in mind the dignity of the patient then both of these positions can and should be used to guide someone at the end of their life.
50 Endnotes
34. Orlando Women’s Center is an example of one of many abortion clinics that will perform late term abortions. All of their services are advertised on their website.
35 ERD part 5-Issues and Care for the Dying Introduction
36. CVSTOS FIDEI is a Catholic Blog that discusses ethics issues and current event topics as they pertain to Catholics.
37. Catechism of the Catholic Church-Section 2269
38. Catechism of the Catholic Church-Section 2276
51
Afterword
Shining Light in the Darkness
Even if one is not Christian, the issues presented in the previous chapters should still matter. Abortion and euthanasia may not challenge everyone morally or spiritually but consideration of these topics is still worthwhile. These issues may not affect every healthcare provider, but they most certainly will affect their patients. If someone is going into the medical field to help people, to relieve suffering, and to make a person whole again, then these life and death issues should matter because they matter to patients.
Future healthcare providers are going to be more successful in future encounters with medical ethics issues by learning how to wrestle with these complex and controversial ideas. It is important to be aware that patients are going to have different beliefs than their physician in many aspects. Patients may disagree with a doctor’s opinion on a course of treatment, and the physician needs to be able to articulate why he thinks his treatment plan is important. In addition, one also has to listen to his patient’s perspective on treatment and hear his concerns and hesitations. Patients come from many unique backgrounds and traditions and they deserve to have their beliefs respected. Medical ethics issues are complex and difficult and future health providers need to develop where they stand on these issues early in their careers. Developing a framework for tackling tough issues is important. It is equally important to have a worldview of all of these issues so as to be able to process each case. A physician needs to be able to tolerate people believing differently than he does as well as be able to stand his ground and maintain his own values. If there is something that challenges someone to his core, he
52 needs to assess this issue and develop a response as well as stand up for what he believes
is right. For example, as a Catholic, I am opposed to any form of birth control that is used
for contraceptive purposes, so I would not prescribe this to patients. In the future, if my
patient needs this treatment then I will refer her to a physician who can provide the
necessary care. This way the patient is taken care of in the best manner possible but as a
physician, I will not have violated what I believe regarding birth control. Just because I
will be a physician does not mean all of my personal beliefs do not matter anymore. Also,
in keeping true to one’s own beliefs, one cannot cause a patient to compromise his own
beliefs in order to follow the physician’s instructions. This becomes complicated when
the views of the physician and patient are opposing as could be seen in the previous
chapters. The one main point to remember amidst all of this is to maintain the dignity of
the patient at all cost. Each patient deserves someone who will love and care for him, not
someone concerned about how to make the most money or prestige. Laws and
government, at times, can make it difficult to be a good doctor. Policies can make it
tough to uphold beliefs as a physician. Working in the medical field where laws and
religion collide is not easy but one has to learn how to reconcile conflicting ideas. Even if
someone is not in the medical field, he will still have his values challenged and he needs
to be aware of how to handle a situation that arises that tests his belief system.
In addition to the challenge of wrestling with the tough issues in medicine, I chose
this topic because I think someone needs to be an advocate for people who cannot advocate for themselves: the old, the unborn, the disabled, the oppressed, the impoverished, etc. Someone has to be sure that the vulnerable are allowed to live the life
God intended with dignity. I want people to be aware that a human being should be
53 respected no matter how compromised, poor, or close to death he might be. I chose this specific idea about end of life care decisions as I was volunteering with the elderly. I saw some of the patients go from coherent and normal to being non-responsive in a matter of weeks. Some of the residents at this facility did not have family to visit them, they had no one to advocate for them. Some of the residents were treated like they had little worth.
Members of the staff gave the patients their medicines and walked away without saying a word to the person lying in the bed. I want to speak up for the patients who cannot do it themselves. They do not deserve to be treated like they are nothing at the end of their life.
I wanted so badly to be able to make the dying process as dignified as possible for the residents that I grew to love. They were old, disabled, and mentally compromised and many of them could have died a more dignified death. I do not think anyone puts in their will that they want to die in a nursing home surrounded by staff who cared more about their next smoke break than the person lying in the bed. It may be too late for the friends I lost at this facility but there are more people dying in nursing homes who deserve better than to die in a way that is un-dignified and against their wishes. I am not suggesting that everyone should follow Catholic doctrine in the dying process although the Catholic
Church does stress the maintenance of dignity and humanity even in the final hours.
When the dying are unable to speak, someone needs to speak up for them and ensure that the final hours of a person’s life are full of dignity.
I always do everything in life with Catholic influence. It is difficult to always follow Catholic doctrine but I try my best. Catholicism does have a huge effect on my interactions, decisions, thoughts, and actions as a college student. I also expect that in my
54 future as a physician, my Catholic faith will stay a consistent part of my practice. The
way I practice medicine in the future will most certainly have a Catholic influence.
Then the Lord said to Cain, “Where is your brother Abel?” “I don't know”, he
replied. “Am I my brother's keeper?” 39 (New American Standard Bible-Genesis 4:9)
There are people in the world who, like Cain, do not care for other people. If something is
not their problem then they feel that they should not have to deal with it. This is not how
people should be thinking. This verse can be applied to the medical field. It does not
matter if someone is poor, homeless, old, handicapped, unborn, black, Native American,
an immigrant: people are here on earth to look after one another. Denying someone a
necessity is not doing what is best to look after the people who God calls each person to
love: the least of these. “The King will reply, ‘Truly I tell you, whatever you did for one
of the least of these brothers and sisters of mine, you did for me’” 40 (New American
Standard Bible-Matthew 25:40). The Ethical and Religious Directives are essentially a guide for how to be your brother’s keeper. The ERDs give support in places where it might not be easy to care for someone who is unresponsive or handicapped. By following the ERDs, one is making sure that each person lives a life and dies a death with as much dignity as possible. Also, the ERDs provide a guide in order to follow what God has commanded His people on earth to do which is to take care of the least of these for these people are our brothers. On earth, the least someone can do is show people the love of
Jesus. In showing them love as a physician, he is not only looking after their bodies, but also their souls. In response to the Lord’s question to Cain, the answer is yes; we are our
brother’s keeper.
55 To conclude, please consider this poem written by an elderly man in a nursing
home. When people are old, sick, and dying, who they used to be becomes hard to define.
People tend to forget that an old man, unresponsive in the ICU, is a son, a father, and a
husband: he had a job, a life, hobbies, passions, and memories. A man in the ICU is not
taking up space, he is a person. Never forget that no matter how compromised a person is, this life still has meaning and worth.
The Cranky Old Man By: Anonymous
What do you see nurses? What do you see? What are you thinking……… when you’re looking at me? A crabby old man……………………. not very wise, Uncertain of habit ……………….. with far away eyes? Who dribbles his food ……………. and makes no reply. When you say in a loud voice …… “I do wish you’d try!” Who seems not to notice ………. the things that you do. And forever is losing ……………….. a sock or shoe? Who, resisting or not ……….. lets you do as you will, With bathing and feeding ……….. the long day to fill? Is that what you’re thinking? …… Is that what you see? Then open your eyes, nurse ….. you’re not looking at me.
I’ll tell you who I am ……….. as I sit here so still, As I do at your bidding, ………. as I eat at your will. I’m a small child of Ten ……. with a father and mother, Brothers and sisters …………… who love one another. A young boy of Sixteen ……….. with wings on his feet. Dreaming that soon now …………… a lover he’ll meet. A groom soon at Twenty ………… my heart gives a leap. Remembering, the vows ……….. that I promised to keep. At Twenty-Five, now ………….. I have young of my own. Who need me to guide ………… and a secure happy home. A man of Thirty …………….. my young now grow fast, Bound to each other ………. with ties that should last. At Forty, my young sons ……… have grown and are gone, But my woman’s beside me ………. so see! I don’t mourn. At Fifty, once more, ……… babies play ’round my knee, Again, we know children …………. my loved one and me.
Dark days are upon me …………… my wife is now dead.
56 I look at the future …………… I shudder with dread. For my young are all rearing ……… young of their own. And I think of the years … and the love that I’ve known. I’m now an old man ……………… and nature is cruel. Tis jest to make old age …………… look like a fool. The body, it crumbles ……….. grace and vigor depart. There is now a stone ……….. where I once had a heart.
But inside this old carcass …. a young guy still dwells, And now and again ………….. my battered heart swells. I remember the joys …………….. I remember the pain. And I’m loving and living …………… life over again. I think of the years …. all too few ….. gone too fast. And accept the stark fact ……… that nothing can last. So open your eyes, people ……………… open and see. Not a crabby old man. Look closer ….. See …… ME!!
57 Endnotes
38. New American Bible (NASB) Genesis 4:9
39. New American Bible (NASB) Matthew: 25:40
58
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