Euthanasia

Physician Assisted Suicide / Death (PAS, PAD)

Hospice

Palliative care

Terminal sedation

Killing vs allowing to die

Case studies

EUTHANASIA: ORIGINALLY; EU – THANATOS (Gk) “TRUE, GOOD – DEATH”

• HISTORICALLY: ACTIVE / PASSIVE EUTHANASIA

• TODAY: “CAUSING DEATH SO AS TO ALLEVIATE SUFFERING” (ERD 60, 61)

Medical definitions of active and passive euthanasia The practice of intentionally ending a life in order to relieve pain and suffering (MedicineNet)

Generic Definition The act or practice of killing or permitting the death of hopelessly sick or injured individuals (such as persons or domestic animals) in a relatively painless way for reasons of mercy (Merriam-Webster Dictionary)

Medical Dictionary (online) deliberate ending of life of a person suffering from an incurable disease Today: include withholding extraordinary means or “heroic measures,” and thus allowing the patient to die Traditionally: positive or active euthanasia (deliberate ending of life and an action is taken to cause death in a person) negative or passive euthanasia (withholding of life-preserving procedures and treatments that would prolong the life of one who is incurably and terminally ill and could not survive without them) Today all euthanasia is generally understood to be active; forgoing life-sustaining treatment is replacing passive euthanasia.

BIOETHICAL DEFINITION OF EUTHANASIA (ERD 60, 61)

60. Euthanasia is an action or omission that of itself or by intention causes death in order to alleviate suffering. Catholic health care institutions may never condone or participate in euthanasia or assisted suicide in any way. Dying patients who request euthanasia should receive loving care, psychological and spiritual support, and appropriate remedies for pain and other symptoms so that they can live with dignity until the time of natural death.

61. 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. Since a person has the right to prepare for his or her death while fully conscious, he or she should not be deprived of consciousness without a compelling reason. Medicines 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 death. Patients experiencing suffering that cannot be alleviated should be helped to appreciate the Christian understanding of redemptive suffering.

PAIN / SUFFERING; W/IN CONTEXT OF FAITH -> REDEMPTIVE VALUE

(JUDEO-CHRISTIAN TRADITION)

DECLARATION ON EUTHANASIA (1980):

http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19800505_euthanasia_en.html

Vicarious reparation

Euthanasia vs physician-assisted suicide / death (PAS, PAD)

AID IN DYING (AID)

MEDICAL AID IN DYING (MAID)

PHYSICIAN AID IN DYING (PAID)

Healthy alternative to euthanasia / PAS:

• HOSPICE • PALLIATIVE CARE

Hospice vs Palliative care In common: patient care

Differences (generally):

Place • Hospice; home • Palliative Care; hospital

Timing • Hospice; 6 months (terminal) • Palliative Care; no specified time (terminal or chronic)

Payment • Hospice; not covered by all insurance (yes Medicare) • Palliative Care; hospital billing

Treatment • Hospice; comfort care (few meds and treatments) • Palliative Care; maybe life-prolonging therapies / meds

Palliative / Terminal Sedation

Relieving distress in a terminally ill person in the last hours or days of a dying patient's life, usually by means of a continuous intravenous or subcutaneous infusion of a sedative drug, or by means of a specialized catheter designed to provide comfortable and discreet administration of ongoing medications via the rectal route.

• Last resort

• Intractable pain

• If to manage pain only (titration), then not euthanasia

• If to sedate patient into unconsciousness –without N / H-, then euthanasia

Analgesic (pain relief): opioids (morphine, hydrocodone, oxycodone, fentanyl)

Sedative (sleeping): benzodiazepines (midazolam, haloperidol, chlorpromazine, pentobarbital, propofol)

Critical bioethical distinction:

KILLING vs ALLOWING TO DIE

Hemlock Society (1980 – 2003):

American right-to-die and assisted suicide advocacy organization

motto: "Good Life, Good Death"

founded (Santa Monica, CA):

Derek and Ann Humphry, Gerald A. Larue, and Faye Girsh

relocated to Oregon in 1988

2003, renamed: End of Life Choices

2004, Derek Humphry and Faye Girsh founded: Final Exit Network

2007, merged: Compassion in Dying Federation -> Compassion & Choices

Jacob "Jack" Kevorkian (1928 – 2011; 83 y/o) "Dr. Death" American pathologist and euthanasia proponent Right to die via physician-assisted suicide assisted at least 130 patients to PAS 1999: arrested and tried for his direct role in a case of voluntary euthanasia convicted of second degree murder served 8 years of a 10-to-25-year prison sentence released on parole 2007: on condition he would not offer advice nor participate nor be present in the act of any type of suicide involving euthanasia to any other person; as well as neither promote nor talk about the procedure of assisted suicide assisted by attaching the individual to a euthanasia device that he had devised and constructed The individual then pushed a button which released the drugs or chemicals that would end his or her own life Studies of those who sought out Dr. Kevorkian, however, suggest that though many had a worsening illness … it was not usually terminal. Autopsies showed five people had no disease at all. … Little over a third were in pain. Some presumably suffered from no more than hypochondria or depression 2011: diagnosed with liver cancer (hepatitis C) hospitalized with kidney problems and pneumonia died from a thrombosis June 3, 2011 (83 y/o)

CASE OF BRITTANY MAYNARD (1984-2014; 29 Y/0):

2012 MARRIED Daniel Diaz, NO CHILDREN, LIVED IN CALIFORNIA JANUARY 2014; DIAGNOSED WITH GRADE 2 ASTROCYTOMA () = TERMINAL BRAIN CANCER Partial craniotomy and a partial resection of her temporal lobe (understanding speech) APRIL 2014; GRADE 4 GLIOCYTOMA; prognosis of six months to live common symptom is headache — affecting about half of all people with a brain tumor. Other symptoms can include seizures, memory loss, physical weakness, loss of muscle control, visual symptoms, language problems, cognitive decline, and personality changes. partnered with Compassion and Choices to create the Brittany Maynard Fund, which seeks to legalize aid in dying in states where it is now illegal MOVED TO OREGON (PAS LEGAL) -> PAS NOVEMBER 2014 September 2015, California lawmakers gave final PAS approval

NATIONAL AND INTERNATIONAL RIPPLE EFFECT

STATES LEGALIZED PAS:

• CALIFORNIA

• COLORADO

• DC

• HAWAII (2018)

• MONTANA

• OREGON (1994)

• WASHINGTON

• VERMONT

“Life is not a problem to be solved, but a mystery to be lived.”

Friedrich Nietsche / Soren Kierkegaard

BENEVOLENCE = TO WILL THE GOOD

BENEFICENCE = DOING THE GOOD

Ethical and Religious Directives for

Catholic Health Care Services

Sixth Edition

UNITED STATES CONFERENCE OF CATHOLIC BISHOPS

2

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

This sixth edition of the Ethical and Religious Directives for Catholic Health Care Services was

developed by the Committee on Doctrine of the United States Conference of Catholic Bishops (USCCB)

and approved by the USCCB at its June 2018 Plenary Assembly. This edition of the Directives replaces

all previous editions, is recommended for implementation by the diocesan bishop, and is authorized for

publication by the undersigned.

Msgr. J. Brian Bransfield, STD

General Secretary, USCCB

Excerpts from The Documents of Vatican II, ed. Walter M. Abbott, SJ, copyright © 1966 by America

Press are used with permission. All rights reserved.

Scripture texts used in this work are taken from the New American Bible, copyright © 1991, 1986, and

1970 by the Confraternity of Christian Doctrine, Washington, DC, 20017 and are used by permission of

the copyright owner. All rights reserved.

Digital Edition, June 2018

Copyright © 2009, 2018, United States Conference of Catholic Bishops, Washington, DC. All rights

reserved. No part of this work may be reproduced or transmitted in any form or by any means, electronic

or mechanical, including photocopying, recording, or by any information storage and retrieval system,

without permission in writing from the copyright holder.

3

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

Contents

4 Preamble

6 General Introduction

8 PART ONE

The Social Responsibility of

Catholic Health Care

Services

10 PART TWO

The Pastoral and Spiritual

Responsibility of Catholic

Health Care

13 PART THREE

The Professional-Patient Relationship

16 PART FOUR

Issues in Care for the Beginning of Life

20 PART FIVE

Issues in Care for the Seriously Ill

and Dying

23 PART SIX

Collaborative Arrangements with

Other Health Care Organizations and Providers

27 Conclusion

4

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

Preamble

Health care in the United States is marked by extraordinary change. Not only is there

continuing change in clinical practice due to technological advances, but the health care system

in the United States is being challenged by both institutional and social factors as well. At the

same time, there are a number of developments within the Catholic Church affecting the

ecclesial mission of health care. Among these are significant changes in religious orders and

congregations, the increased involvement of lay men and women, a heightened awareness of

the Church’s social role in the world, and developments in moral theology since the Second

Vatican Council. A contemporary understanding of the Catholic health care ministry must take

into account the new challenges presented by transitions both in the Church and in American

society.

Throughout the centuries, with the aid of other sciences, a body of moral principles has

emerged that expresses the Church’s teaching on medical and moral matters and has proven to

be pertinent and applicable to the ever-changing circumstances of health care and its delivery. In

response to today’s challenges, these same moral principles of Catholic teaching provide the

rationale and direction for this revision of the Ethical and Religious Directives for Catholic

Health Care Services.

These Directives presuppose our statement Health and Health Care published in 1981.1

There we presented the theological principles that guide the Church’s vision of health care,

called for all Catholics to share in the healing mission of the Church, expressed our full

commitment to the health care ministry, and offered encouragement to all those who are

involved in it. Now, with American health care facing even more dramatic changes, we

reaffirm the Church’s commitment to health care ministry and the distinctive Catholic identity

of the Church’s institutional health care services.2 The purpose of these Ethical and Religious

Directives then is twofold: first, to reaffirm the ethical standards of behavior in health care that

flow from the Church’s teaching about the dignity of the human person; second, to provide

authoritative guidance on certain moral issues that face Catholic health care today.

The Ethical and Religious Directives are concerned primarily with institutionally based

Catholic health care services. They address the sponsors, trustees, administrators, chaplains,

physicians, health care personnel, and patients or residents of these institutions and services.

Since they express the Church’s moral teaching, these Directives also will be helpful to Catholic

professionals engaged in health care services in other settings. The moral teachings that we

profess here flow principally from the natural law, understood in the light of the revelation

Christ has entrusted to his Church. From this source the Church has derived its understanding

of the nature of the human person, of human acts, and of the goals that shape human activity.

The Directives have been refined through an extensive process of consultation with bishops,

theologians, sponsors, administrators, physicians, and other health care providers. While providing

standards and guidance, the Directives do not cover in detail all of the complex issues that confront

Catholic health care today. Moreover, the Directives will be reviewed periodically by the United

States Conference of Catholic Bishops (formerly the National Conference of Catholic Bishops), in

the light of authoritative church teaching, in order to address new insights from theological and

5

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

medical research or new requirements of public policy.

The Directives begin with a general introduction that presents a theological basis for the

Catholic health care ministry. Each of the six parts that follow is divided into two sections. The

first section is in expository form; it serves as an introduction and provides the context in which

concrete issues can be discussed from the perspective of the Catholic faith. The second section is

in prescriptive form; the directives promote and protect the truths of the Catholic faith as those

truths are brought to bear on concrete issues in health care.

6

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

General Introduction The Church has always sought to embody our Savior’s concern for the sick. The gospel

accounts of Jesus’ ministry draw special attention to his acts of healing: he cleansed a man

with leprosy (Mt 8:1-4; Mk 1:40-42); he gave sight to two people who were blind (Mt 20:29-

34; Mk 10:46-52); he enabled one who was mute to speak (Lk 11:14); he cured a woman who

was hemorrhaging (Mt 9:20-22; Mk 5:25-34); and he brought a young girl back to life (Mt

9:18, 23-25; Mk 5:35-42). Indeed, the Gospels are replete with examples of how the Lord

cured every kind of ailment and disease (Mt 9:35). In the account of Matthew, Jesus’ mission

fulfilled the prophecy of Isaiah: “He took away our infirmities and bore our diseases” (Mt

8:17; cf. Is 53:4).

Jesus’ healing mission went further than caring only for physical affliction. He touched

people at the deepest level of their existence; he sought their physical, mental, and spiritual

healing (Jn 6:35, 11:25-27). He “came so that they might have life and have it more

abundantly” (Jn 10:10).

The mystery of Christ casts light on every facet of Catholic health care: to see Christian

love as the animating principle of health care; to see healing and compassion as a continuation

of Christ’s mission; to see suffering as a participation in the redemptive power of Christ’s

passion, death, and resurrection; and to see death, transformed by the resurrection, as an

opportunity for a final act of communion with Christ.

For the Christian, our encounter with suffering and death can take on a positive and

distinctive meaning through the redemptive power of Jesus’ suffering and death. As St. Paul

says, we are “always carrying about in the body the dying of Jesus, so that the life of Jesus

may also be manifested in our body” (2 Cor 4:10). This truth does not lessen the pain and fear,

but gives confidence and grace for bearing suffering rather than being overwhelmed by it.

Catholic health care ministry bears witness to the truth that, for those who are in Christ,

suffering and death are the birth pangs of the new creation. “God himself will always be with

them [as their God]. He will wipe every tear from their eyes, and there shall be no more death

or mourning, wailing or pain, [for] the old order has passed away” (Rev 21:3-4).

In faithful imitation of Jesus Christ, the Church has served the sick, suffering, and dying in

various ways throughout history. The zealous service of individuals and communities has

provided shelter for the traveler; infirmaries for the sick; and homes for children, adults, and

the elderly.3 In the United States, the many religious communities as well as dioceses that

sponsor and staff this country’s Catholic health care institutions and services have established

an effective Catholic presence in health care. Modeling their efforts on the gospel parable of

the Good Samaritan, these communities of women and men have exemplified authentic

neighborliness to those in need (Lk 10:25-37). The Church seeks to ensure that the service

offered in the past will be continued into the future.

While many religious communities continue their commitment to the health care ministry,

lay Catholics increasingly have stepped forward to collaborate in this ministry. Inspired by the

example of Christ and mandated by the Second Vatican Council, lay faithful are invited to a

broader and more intense field of ministries than in the past.4 By virtue of their Baptism, lay

7

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

faithful are called to participate actively in the Church’s life and mission.5 Their participation

and leadership in the health care ministry, through new forms of sponsorship and governance

of institutional Catholic health care, are essential for the Church to continue her ministry of

healing and compassion. They are joined in the Church’s health care mission by many men

and women who are not Catholic.

Catholic health care expresses the healing ministry of Christ in a specific way within the

local church. Here the diocesan bishop exercises responsibilities that are rooted in his office as

pastor, teacher, and priest. As the center of unity in the diocese and coordinator of ministries

in the local church, the diocesan bishop fosters the mission of Catholic health care in a way

that promotes collaboration among health care leaders, providers, medical professionals,

theologians, and other specialists. As pastor, the diocesan bishop is in a unique position to

encourage the faithful to greater responsibility in the healing ministry of the Church. As

teacher, the diocesan bishop ensures the moral and religious identity of the health care

ministry in whatever setting it is carried out in the diocese. As priest, the diocesan bishop

oversees the sacramental care of the sick. These responsibilities will require that Catholic

health care providers and the diocesan bishop engage in ongoing communication on ethical

and pastoral matters that require his attention.

In a time of new medical discoveries, rapid technological developments, and social change,

what is new can either be an opportunity for genuine advancement in human culture, or it can

lead to policies and actions that are contrary to the true dignity and vocation of the human

person. In consultation with medical professionals, church leaders review these developments,

judge them according to the principles of right reason and the ultimate standard of revealed

truth, and offer authoritative teaching and guidance about the moral and pastoral

responsibilities entailed by the Christian faith.6 While the Church cannot furnish a ready

answer to every moral dilemma, there are many questions about which she provides

normative guidance and direction. In the absence of a determination by the magisterium, but

never contrary to church teaching, the guidance of approved authors can offer appropriate

guidance for ethical decision making.

Created in God’s image and likeness, the human family shares in the dominion that Christ

manifested in his healing ministry. This sharing involves a stewardship over all material

creation (Gn 1:26) that should neither abuse nor squander nature’s resources. Through science

the human race comes to understand God’s wonderful work; and through technology it must

conserve, protect, and perfect nature in harmony with God’s purposes. Health care

professionals pursue a special vocation to share in carrying forth God’s life-giving and

healing work.

The dialogue between medical science and Christian faith has for its primary purpose the

common good of all human persons. It presupposes that science and faith do not contradict

each other. Both are grounded in respect for truth and freedom. As new knowledge and new

technologies expand, each person must form a correct conscience based on the moral norms

for proper health care.

8

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

PART ONE

The Social Responsibility of Catholic Health Care Services

Introduction

Their embrace of Christ’s healing mission has led institutionally based Catholic health care

services in the United States to become an integral part of the nation’s health care system.

Today, this complex health care system confronts a range of economic, technological, social,

and moral challenges. The response of Catholic health care institutions and services to these

challenges is guided by normative principles that inform the Church’s healing ministry.

First, Catholic health care ministry is rooted in a commitment to promote and defend

human dignity; this is the foundation of its concern to respect the sacredness of every human

life from the moment of conception until death. The first right of the human person, the right

to life, entails a right to the means for the proper development of life, such as adequate

health care.7

Second, the biblical mandate to care for the poor requires us to express this in concrete

action at all levels of Catholic health care. This mandate prompts us to work to ensure that our

country’s health care delivery system provides adequate health care for the poor. In Catholic

institutions, particular attention should be given to the health care needs of the poor, the

uninsured, and the underinsured.8 Third, Catholic health care ministry seeks to contribute to

the common good. The common good is realized when economic, political, and social

conditions ensure protection for the fundamental rights of all individuals and enable all to

fulfill their common purpose and reach their common goals.9

Fourth, Catholic health care ministry exercises responsible stewardship of available health

care resources. A just health care system will be concerned both with promoting equity of

care—to assure that the right of each person to basic health care is respected—and with

promoting the good health of all in the community. The responsible stewardship of health care

resources can be accomplished best in dialogue with people from all levels of society, in

accordance with the principle of subsidiarity and with respect for the moral principles that

guide institutions and persons.

Fifth, within a pluralistic society, Catholic health care services will encounter requests for

medical procedures contrary to the moral teachings of

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