Is prenatal testing allowable by the Magisterium of the Roman Catholic Church?

According to Donum Vitae: For prenatal diagnosis makes it possible to know the condition of the embryo and of the fetus when still in the mother’s womb. It permits, or makes it possible to anticipate earlier and more effectively, certain therapeutic, medical or surgical procedures. Such diagnosis is permissible, with the consent of the parents after they have been adequately informed, if the methods employed safeguard the life and integrity of the embryo and the mother, without subjecting them to disproportionate risks.

But this diagnosis is gravely opposed to the moral law when it is done with the thought of possibly inducing an abortion depending upon the results: a diagnosis which shows the existence of a malformation or a hereditary illness must not be the equivalent of a death-sentence. Thus a woman would be committing a gravely illicit act if she were to request such a diagnosis with the deliberate intention of having an abortion should the results confirm the existence of a malformation or abnormality. The spouse or relatives or anyone else would similarly be acting in a manner contrary to the moral law if they were to counsel or impose such a diagnostic procedure on the expectant mother with the same intention of possibly proceeding to an abortion. So too the specialist would be guilty of illicit collaboration if, in conducting the diagnosis and in communicating its results, he were deliberately to contribute to establishing or favoring a link between prenatal diagnosis and abortion. In conclusion, any directive or program of the civil and health authorities or of scientific organizations which in any way were to favor a link between prenatal diagnosis and abortion, or which were to go as far as directly to induce expectant mothers to submit to prenatal diagnosis planned for the purpose of eliminating fetuses which are affected by malformations or which are carriers of hereditary illness, is to be condemned as a violation of the unborn child’s right to life and as an abuse of the prior rights and duties of the spouses.

 

Congregation for the Doctrine of the Faith, Instruction on Respect For Human Life In Its Origin And On The Dignity Pf Procreation Replies To Certain Questions Of The Day, #2.

 

What is the Catholic Church’s position on extraordinary/ordinary means of treatment and care?

Declaration on Euthanasia:

IV.
DUE PROPORTION IN THE USE OF REMEDIES

Today it is very important to protect, at the moment of death, both the dignity of the human person and the Christian concept of life, against a technological attitude that threatens to become an abuse. Thus some people speak of a “right to die,” which is an expression that does not mean the right to procure death either by one’s own hand or by means of someone else, as one pleases, but rather the right to die peacefully with human and Christian dignity. From this point of view, the use of therapeutic means can sometimes pose problems. In numerous cases, the complexity of the situation can be such as to cause doubts about the way ethical principles should be applied. In the final analysis, it pertains to the conscience either of the sick person, or of those qualified to speak in the sick person’s name, or of the doctors, to decide, in the light of moral obligations and of the various aspects of the case. Everyone has the duty to care for his or he own health or to seek such care from others. Those whose task it is to care for the sick must do so conscientiously and administer the remedies that seem necessary or useful. However, is it necessary in all circumstances to have recourse to all possible remedies? In the past, moralists replied that one is never obliged to use “extraordinary” means. This reply, which as a principle still holds good, is perhaps less clear today, by reason of the imprecision of the term and the rapid progress made in the treatment of sickness. Thus some people prefer to speak of “proportionate” and “disproportionate” means. In any case, it will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources. In order to facilitate the application of these general principles, the following clarifications can be added: – If there are no other sufficient remedies, it is permitted, with the patient’s consent, to have recourse to the means provided by the most advanced medical techniques, even if these means are still at the experimental stage and are not without a certain risk. By accepting them, the patient can even show generosity in the service of humanity. – It is also permitted, with the patient’s consent, to interrupt these means, where the results fall short of expectations. But for such a decision to be made, account will have to be taken of the reasonable wishes of the patient and the patient’s family, as also of the advice of the doctors who are specially competent in the matter. The latter may in particular judge that the investment in instruments and personnel is disproportionate to the results foreseen; they may also judge that the techniques applied impose on the patient strain or suffering out of proportion with the benefits which he or she may gain from such techniques. – It is also permissible to make do with the normal means that medicine can offer. Therefore one cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community. – When inevitable death is imminent in spite of the means used, it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted. In such circumstances the doctor has no reason to reproach himself with failing to help the person in danger.

Congregation for the Doctrine of the Faith, Declaration on Euthanasia, May 5, 1980

What is the Catholic Church’s position on suicide and Physician-Assisted Suicide?

 

I.
THE VALUE OF HUMAN LIFE

Human life is the basis of all goods, and is the necessary source and condition of every human activity and of all society. Most people regard life as something sacred and hold that no one may dispose of it at will, but believers see in life something greater, namely, a gift of God’s love, which they are called upon to preserve and make fruitful. And it is this latter consideration that gives rise to the following consequences:

  1. No one can make an attempt on the life of an innocent person without opposing God’s love for that person, without violating a fundamental right, and therefore without committing a crime of the utmost gravity.[4]
  2. Everyone has the duty to lead his or her life in accordance with God’s plan. That life is entrusted to the individual as a good that must bear fruit already here on earth, but that finds its full perfection only in eternal life.
  3. Intentionally causing one’s own death, or suicide, is therefore equally as wrong as murder; such an action on the part of a person is to be considered as a rejection of God’s sovereignty and loving plan. Furthermore, suicide is also often a refusal of love for self, the denial of a natural instinct to live, a flight from the duties of justice and charity owed to one’s neighbor, to various communities or to the whole of society – although, as is generally recognized, at times there are psychological factors present that can diminish responsibility or even completely remove it. However, one must clearly distinguish suicide from that sacrifice of one’s life whereby for a higher cause, such as God’s glory, the salvation of souls or the service of one’s brethren, a person offers his or her own life or puts it in danger (cf. Jn. 15:14).

Congregation for the Doctrine of the Faith, Declaration on Euthanasia,
May 5, 1980

 II.  Catechism of the Catholic Church:

Euthanasia

2276 Those whose lives are diminished or weakened deserve special respect. Sick or handicapped persons should be helped to lead lives as normal as possible.

2277 Whatever its motives and means, 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 excluded.

2278 Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of “over-zealous” treatment. Here one does not will to cause death; one’s inability to impede it is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected.

2279 Even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted. The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only foreseen and tolerated as inevitable Palliative care is a special form of disinterested charity. As such it should be encouraged.

Suicide

2280 Everyone is responsible for his life before God who has given it to him. It is God who remains the sovereign Master of life. We are obliged to accept life gratefully and preserve it for his honor and the salvation of our souls. We are stewards, not owners, of the life God has entrusted to us. It is not ours to dispose of.

2281 Suicide contradicts the natural inclination of the human being to preserve and perpetuate his life. It is gravely contrary to the just love of self. It likewise offends love of neighbor because it unjustly breaks the ties of solidarity with family, nation, and other human societies to which we continue to have obligations. Suicide is contrary to love for the living God.

2282 If suicide is committed with the intention of setting an example, especially to the young, it also takes on the gravity of scandal. Voluntary co-operation in suicide is contrary to the moral law.

Grave psychological disturbances, anguish, or grave fear of hardship, suffering, or torture can diminish the responsibility of the one committing suicide.

2283 We should not despair of the eternal salvation of persons who have taken their own lives. By ways known to him alone, God can provide the opportunity for salutary repentance. The Church prays for persons who have taken their own lives.

 

Is the Catholic Church against all forms of stem cell research?

The answer is No. The Catholic Church is only against some forms of Embryonic Stem Cell Research (ESCR) that entail the destruction of human embryos. Stem cells are cells that develop very early in the human embryo after fertilization. Stem cells “have the remarkable potential to develop into many different cell types in the body during early life and growth. In addition, in many tissues they serve as a sort of internal repair system, dividing essentially without limit to replenish other cells as long as the person or animal is still alive. When a stem cell divides, each new cell has the potential either to remain a stem cell or become another type of cell with a more specialized function, such as a muscle cell, a red blood cell, or a brain cell” (National Institute of Health, Stem Cell Basics, 2015). Proponents of ESCR believe it has the potential of being a renewable source of replacement cells and tissues that could treat plethora of diseases such as Parkinson’s, amyotrophic lateral sclerosis, spinal cord injuries, burns, heart disease, diabetes, arthritis and many more. They argue that since ESCR hold these “great” potentials, it is justified to experiment on embryonic stem cells retrieved by any means available (induce abortion of early embryos to retrieve their stem cells, produce/create embryos in vitro for the sole purpose of research, use “leftover” embryos from in vitro fertilization (IVF) and so on. The end in this context justifies the means. On the contrary, the moral objection to some forms of ESCR stems from the fact that stem cells harvested from living 3-5 days old embryos (blastocysts) will ultimately result in the destruction of a young human being. This objection against ESCR does not imply opposition to stem cell research generally. Most types of stem cell research (especially adult stem cell research) and morally acceptable forms of ESCR are encouraged. Stem cells can be derived from these morally acceptable sources: Embryonic Germ Cells (from miscarriages or spontaneous abortions and not elective abortions), Umbilical Cord Stem Cells, Placenta-derived Stem Cells, Post-Natally Derived (Adult) Stem cells, De-Differentiation Strategies (provided it doesn’t go so far as to make a human embryo), and Reprogramming Strategies (as long it generates a distinctly non-embryonic entity).

The Church’s objection to some forms of stem cell research is expressed in Donum Vitae no. 4: “Medical research must refrain from operations on live embryos, unless there is a moral certainty of not causing harm to the life or integrity of the unborn child and the mother, and on condition that the parents have givers their free and informed consent to the procedure. It follows that all research, even when limited to the simple observation of the embryo, would become illicit were it to involve risk to the embryo’s physical integrity or life by reason of the methods used or the effects induced. As regards experimentation, and presupposing the general distinction between experimentation for purposes which are not directly therapeutic and experimentation which is clearly therapeutic for the subject himself, in the case in point one must also distinguish between experimentation carried out on embryos which are still alive and experimentation carried out on embryos which are dead. If the embryos are living, whether viable or not, they must be respected just like any other human person; experimentation on embryos which is not directly therapeutic is illicit. (29) No objective, even though noble in itself, such as a foreseeable advantage to science, to other human beings or to society, can in any way justify experimentation on living human embryos or fetuses, whether viable or not, either inside or outside the mother’s womb” (Congregation for the Doctrine of Faith, 1987).

Is Surrogate Motherhood Ethical for the Roman Catholic Church?

No, for the same reasons which lead one to reject heterologous artificial fertilization: for it is contrary to the unity of marriage and to the dignity of the procreation of the human person. Surrogate motherhood represents an objective failure to meet the obligations of maternal love, of conjugal fidelity and of responsible motherhood; it offends the dignity and the right of the child to be conceived, carried in the womb, brought into the world and brought up by his own parents; it sets up, to the detriment of families, a division between the physical, psychological and moral elements which constitute those families.

* By “surrogate mother” the Instruction means:

  1. a) the woman who carries in pregnancy an embryo implanted in her uterus and who is genetically a stranger to the embryo because it has been obtained through the union of the gametes of “donors”. She carries the pregnancy with a pledge to surrender the baby once it is born to the party who commissioned or made the agreement for the pregnancy.
  2. b) the woman who carries in pregnancy an embryo to whose procreation she has contributed the donation of her own ovum, fertilized through insemination with the sperm of a man other than her husband. She carries the pregnancy with a pledge to surrender the child once it is born to the party who commissioned or made the agreement for the pregnancy.

 

Congregation for the Doctrine of the Faith, Instruction On Respect for Human Life In Its Origin and on the Dignity of Procreation Replies to Certain Questions of the Day.

Example of Living Will

DURABLE HEALTH CARE POWER OF ATTORNEY AND HEALTH CARE TREATMENT INSTRUCTIONS LIVING WILL

PART I

INTRODUCTORY REMARKS ON HEALTH CARE DECISION MAKING

You have the right to decide the type of health care you want. Should you become unable to understand, make, or communicate decisions about medical care, your wishes for medical treatment are most likely to be followed if you express those wishes in advance by:

(1) naming a health care agent to decide treatment for you; and

(2) giving health care treatment instructions to your health care agent or health care provider.

An advance health care directive is a written set of instructions expressing your wishes for medical treatment. It may contain a health care power of attorney, where you name a person called a “health care agent” to decide treatment for you, and a living will, where you tell your health care agent and health care providers your choices regarding the initiation, continuation, withholding, or withdrawal of life-sustaining treatment and other specific instructions.

You may limit your health care agent’s involvement in deciding your medical treatment so that your health care agent will speak for you only when you are unable to speak for yourself or you may give your health care agent the power to speak for you immediately. THIS COMBINED FORM GIVES YOUR HEALTH CARE AGENT THE POWER TO SPEAK FOR YOU ONLY WHEN YOU ARE UNABLE TO SPEAK FOR YOURSELF.

A living will cannot be followed unless your attending physician determines that you lack the ability to understand, make, and communicate health care decisions for yourself and you are either permanently unconscious or you have an end-stage medical condition, which is a condition that will result in death despite the introduction or continuation of medical treatment. You, and not your health care agent, remain responsible for the cost of your medical care.

If you do not write down your wishes about your health care in advance, and if later you become unable to understand, make, or communicate these decisions, those wishes may not be honored because they may remain unknown to others.

A health care provider who refuses to honor your wishes about health care must tell you of its refusal and help to transfer you to a health care provider who will honor your wishes.

You should give a copy of your advance health care directive (a living will, health care power of attorney or a document containing both) to your health care agent, your physicians, family members, and others whom you expect would likely attend to your
needs if you become unable to understand, make, or communicate decisions about medical care.

If your health care wishes change, tell your physician and write a new advance health care directive to replace your old one. It is important in selecting a health care agent that you choose a person you trust who is likely to be available in a medical situation where you cannot make decisions for yourself. You should inform that person that you have appointed him or her as your health care agent and discuss your beliefs and values with him or her so that your health care agent will understand your health care objectives.

You may wish to consult with knowledgeable, trusted individuals such as family members, your physician, or clergy when considering an expression of your values and health care wishes. You are free to create your own advance health care directive to convey your wishes regarding medical treatment.
The following form is an example of an advance health care directive that combines a health care power of attorney with a living will.

NOTES ABOUT THE USE OF THIS FORM

If you decide to use this form or create your own advance health care directive, you should consult with your physician and your attorney to make sure that your wishes are clearly expressed and comply with the law.

If you decide to use this form but disagree with any of its statements, you may cross out those statements. You may add comments to this form or use your own form to help your physician or health care agent decide your medical care.

This form is designed to give your health care agent broad powers to make health care decisions for you whenever you cannot make them for yourself. It is also designed to express a desire to limit or authorize care if you have an end-stage medical condition or are permanently unconscious.

If you do not desire to give your health care agent broad powers, or you do not wish to limit your care if you have an end-stage medical condition or are permanently unconscious, you may wish to use a different form or create your own. You should also use a different form if you wish to express your preferences in more detail than this form allows or if you wish for your health care agent to be able to speak for you immediately. In these situations, it is particularly important that you consult with your attorney and physician to make sure that your wishes are clearly expressed.

This form allows you to tell your health care agent your goals if you have an end-stage medical condition or other extreme and irreversible medical condition, such as advanced Alzheimer’s disease. Do you want medical care applied aggressively in these situations or would you consider such aggressive medical care burdensome and undesirable?

You may choose whether you want your health care agent to be bound by your instructions or whether you want your health care agent to be able to decide at the time what course of treatment the health care agent thinks most fully reflects your wishes and values.

If you are a woman and diagnosed as being pregnant at the time a health care decision would otherwise be made pursuant to this form, the laws of this Commonwealth prohibit implementation of that decision if it directs that life-sustaining treatment, including nutrition and hydration, be withheld or withdrawn from you, unless your attending physician and an obstetrician who have examined you certify in your medical record that the life-sustaining treatment:

(1) will not maintain you in such a way as to permit the continuing development and live birth of the unborn child;
(2) will be physically harmful to you; or
(3) will cause pain to you that cannot be alleviated by medication.

A physician is not required to perform a pregnancy test on you unless the physician has reason to believe that you may be pregnant. Pennsylvania law protects your health care agent and health care providers from any legal liability for following in good faith your wishes as expressed in the form or by your health care agent’s direction. It does not otherwise change professional standards or excuse negligence in the way your wishes are carried out. If you have any questions about the law, consult an attorney for guidance.

This form and explanation is not intended to take the place of specific legal or medical advice for which you should rely upon your own attorney and physician.

PART II
DURABLE HEALTH CARE POWER OF ATTORNEY

I,___________________, of_______________County, Pennsylvania, appoint the person named below to be my health care agent to make health and personal care decisions for me.

Effective immediately and continuously until my death or revocation by a writing signed by me or someone authorized to make health care treatment decisions for me, I authorize all health care providers or other covered entities to disclose to my health care agent, upon my agent’s request, any information, oral or written, regarding my physical or mental health, including, but not limited to, medical and hospital records and what is otherwise private, privileged, protected or personal health information, such as health information as defined and described in the Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191, 110 Stat. 1936), the regulations promulgated thereunder and any other State or local laws and rules. Information disclosed by a health care provider or other covered entity may be re-disclosed and may no longer be subject to the privacy rules provided by 45 C.F.R. Pt. 164. 3

The remainder of this document will take effect when and only when I lack the ability to understand, make or communicate a choice regarding a health or personal care decision as verified by my attending physician. My health care agent may not delegate the authority to make decisions.

MY HEALTH CARE AGENT HAS ALL OF THE FOLLOWING POWERS SUBJECT TO THE HEALTH CARE TREATMENT INSTRUCTIONS THAT FOLLOW IN PART III (Cross out any powers you do not want to give your health care agent):

1. To authorize, withhold or withdraw medical care and surgical procedures.
2. To authorize, withhold or withdraw nutrition (food) or hydration (water) medically supplied by tube through my nose, stomach, intestines, arteries or veins.
3. To authorize my admission to or discharge from a medical, nursing, residential or similar facility and to make agreements for my care and health insurance for my    care, including hospice and/or palliative care.
4. To hire and fire medical, social service and other support personnel responsible for my care.
5. To take any legal action necessary to do what I have directed.
6. To request that a physician responsible for my care issue a do-not-resuscitate (DNR) order, including an out-of-hospital DNR order, and sign any required documents and consents.

APPOINTMENT OF HEALTH CARE AGENT

I appoint the following health care agent:

Health Care Agent _________________________________________________
(Name and relationship)

Address:____________________________________________________________________

Telephone Number: Home____________________Work_________________________

E-MAIL:_____________________________________

IF YOU DO NOT NAME A HEALTH CARE AGENT, HEALTH CARE PROVIDERS WILL ASK YOUR FAMILY OR AN ADULT WHO KNOWS YOUR PREFERENCES AND VALUES FOR HELP IN DETERMINING YOUR WISHES FOR TREATMENT.

NOTE: THAT YOU MAY NOT APPOINT YOUR DOCTOR OR OTHER HEALTH CARE PROVIDER AS YOUR HEALTH CARE AGENT, UNLESS RELATED TO YOU BY BLOOD, MARRIAGE OR ADOPTION.

If my health care agent is not readily available or if my health care agent is my spouse and an action for divorce is filed by either of us after the date of this document, I appoint the person or persons named below in the order named. (It is helpful, but not required, to name alternative health care agents.)

First Alternative Health Care Agent:_____________________________________________
(Name and relationship)

Address:________________________________________________________________________

Telephone Number: Home__________________________ Work_______________________

E-MAIL:____________________________________________

Second Alternative Health Care Agent:__________________________________________
(Name and relationship)

Address:_________________________________________________________________________

Telephone Number: Home__________________________ Work________________________

E-MAIL:_____________________________________________

GUIDANCE FOR HEALTH CARE AGENT (OPTIONAL)

GOALS

If I have an end-stage medical condition or other extreme irreversible medical condition, my goals in making medical decisions are as follows (insert your personal priorities such as comfort, care, preservation of mental function, etc.)

SEVERE BRAIN DAMAGE OR BRAIN DISEASE

If I should suffer from severe and irreversible brain damage or brain disease with no realistic hope of significant recovery, I would consider such a condition intolerable and the application of aggressive medical care to be burdensome.

I therefore request that my health care agent respond to any intervening (other and separate) life-threatening conditions in the same manner as directed for an end-stage medical condition or state of permanent unconsciousness as I have indicated below.

Initials________I agree Initials_________I disagree

PART III

HEALTH CARE TREATMENT INSTRUCTIONS IN THE EVENT OF END-STAGE MEDICAL CONDITION OR PERMANENT UNCONSCIOUSNESS (LIVING WILL)
The following health care treatment instructions exercise my right to make my own health care decisions. These instructions are intended to provide clear and convincing evidence of my wishes to be followed when I lack the capacity to understand, make, or communicate my treatment decisions:
If I have an end-stage medical condition (which will result in my death, despite the introduction or continuation of medical treatment) or am permanently unconscious such as in an irreversible coma or irreversible vegetative state and there is no realistic hope of significant recovery, all of the following apply (cross out any treatment instructions with which you do not agree):

1. I direct that I be given health care treatment to relieve pain or provide comfort even if such treatment might shorten my life, suppress my appetite or my breathing, or be habit forming.
2. I direct that all life prolonging procedures be withheld or withdrawn.
3. I specifically do not want any of the following as life prolonging procedures: (If you wish to receive any of these treatments, write “I do want” after the treatment)

  • heart-lung resuscitation (CPR) _______________________________________
  • mechanical ventilator (breathing machine) __________________________
  • dialysis (kidney machine) ___________________________________________
  • surgery _____________________________________________________________
  • chemotherapy radiation treatment __________________________________
  • antibiotics __________________________________________________________

Please indicate whether you want nutrition (food) or hydration (water) medically supplied by a tube into your nose, stomach, intestine, arteries, or veins if you have an
end-stage medical condition or are permanently unconscious and there is no realistic hope of significant recovery.

(Initial only one statement.)

TUBE FEEDINGS
_____I want tube feedings to be given.

                 OR

NO TUBE FEEDINGS
_____I do not want tube feedings to be given.

HEALTH CARE AGENT’S USE OF INSTRUCTIONS

(INITIAL ONE OPTION ONLY.)
_____My health care agent must follow these instructions.
OR
_____These instructions are only guidance.

My health care agent shall have final say and may override any of my instructions. (Indicate any exceptions)

If I did not appoint a health care agent, these instructions shall be followed.

LEGAL PROTECTION

Pennsylvania law protects my health care agent and health care providers from any legal liability for their good faith actions in following my wishes as expressed in this form or in complying with my health care agent’s direction. On behalf of myself, my executors and heirs, I further hold my health care agent and my health care providers harmless and indemnify them against any claim for their good faith actions in recognizing my health care agent’s authority or in following my treatment instructions.

ORGAN DONATION (INITIAL ONE OPTION ONLY.)

_____ I consent to donate my organs and tissues at the time of my death for the purpose of transplant, medical study or education. (Insert any limitations you desire on donation of specific organs or tissues or uses for donation of organs and tissues.)

                                                         OR
_____ I do not consent to donate my organs or tissues at the time of my death.

Having carefully read this document, I have signed it this_____day of______________________, 20__, revoking all previous health care powers of attorney and health care treatment instructions.

SIGNED: ____________________________________________________
(SIGN FULL NAME HERE FOR HEALTH CARE POWER OF ATTORNEY AND HEALTH CARE TREATMENT INSTRUCTIONS)

WITNESS: ___________________________________________

WITNESS: ___________________________________________

Two witnesses at least 18 years of age are required by Pennsylvania law and should witness your signature in each other’s presence. A person who signs this document on behalf of and at the direction of a principal may not be a witness. (It is preferable if the witnesses are not your heirs, nor your creditors, nor employed by any of your health care providers.)

NOTARIZATION (OPTIONAL)

(Notarization of document is not required by Pennsylvania law, but if the document is both witnessed and notarized, it is more likely to be honored by the laws of some other states.)

On this_____day of _________________, 20____, before me personally appeared the aforesaid declarant and principal, to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal in the County of________________, State of______________________ the day and year first above written.

____________________________________________
Notary Public

My commission expires ______________________

Truth-Telling in Medicine: Cultural Dimension

Question:  My mom, who has lived in a small farm village in rural China all her life, became severely ill, and I the daughter decide to send her to the United States to find out what’s wrong with her. I take mom to a specialist and accompany her for all the tests. The diagnostic tests show that mom has terminal cancer and that no effective treatment is available. I insist that the doctor not tell mom because I fear the bad news would destroy her. Is it ethical to withhold information from a patient? Is a patient’s cultural background an important factor in truth telling?

In our August 2009 blog we discussed truth telling in medicine. We suggested that debates about truth telling are complex but they usually come down to disagreements about the limits of paternalism and the proper balance between the physician’s duty of beneficience and the patient’s right of autonomy. An analogy to paternalism is the relationship between a father and his child. A father acts beneficently (i.e. in accordance with his conception of the best interests of his child) when he makes decisions relating to his child’s welfare without consulting him. In like manner, realizing that he has superior training, knowledge and insight in health matters, a physician is in an authoritative position – analogous to a father – to determine a patient’s best interests. He acts paternalistically – and in his mind beneficently – when he makes healthcare decisions unilaterally without soliciting the input of his patients.

The case study above is an example of paternalism. In a reversal of roles, the daughter is acting paternalistically towards her mother when she asks the physician to withhold the diagnosis of terminal cancer because she fears that the bad news would destroy her mother. If the physician were to comply with the daughter’s wishes, he would be participating in the paternalistic behavior of the daughter. What are the limits of paternalism? What is the proper balance between the physician’s duty of beneficence and the patient’s right of autonomy? The two characters in our case study are Chinese. Does country of origin impact truth telling?

We will discuss the dominant traditional attitudes towards truth telling in China, Japan, Lebanon and the United States. China and Japan have a strong paternalistic tradition toward truth telling. Lebanon is going through a transition from a tradition of paternalism to a modern embrace of the principle of patient autonomy. And in the United States the principle of patient autonomy rules over the tradition of paternalism.

A paternalistic attitude toward truth telling in medicine is dominant in China[i]. Influenced by the philosophies of Confucianism and Taoism, the tradition of Chinese ethics emphasizes the good behavior of the practicing physician rather than a system of principles and rules. In Chinese tradition a good physician is paternalistic. Accordingly, he would not disclose to a patient that he has terminal cancer; rather he would tell the spouse or other close family member.  In China families want to hear the news first.  They care for their sick at home, rather than in institutions. Family bonds are so strong in China that they would rather bear the psychological shock of the bad news of a terminal diagnosis rather than share it with their loved one. They want their dear family member to remain hopeful and optimistic. And for their part, patients prefer not to be informed of a terminal illness. They willingly relinquish their right to autonomy and let family members make health care decisions for them.

Japan has a similar paternalistic tradition[ii]. In 1995 the Ministry of Health and Welfare reported the results of a truth telling survey in Japan. It found that only 30% of patients were told they have terminal cancer and that 67% of families felt satisfied that the diagnosis was withheld from them. In Japan physicians usually disclose a terminal diagnosis to family members, not the patient. Like the Chinese, the Japanese feel that disclosure of such bad news brings loss of hope and unwanted emotional distress which may lead to isolation, depression and even suicide.  There are strong authoritarian and paternalistic elements in the Japanese healthcare system. For example, even during routine check-ups, physicians often do not fully explain to the patient the reason for a planned examination and don’t disclose test results directly to them. Drugs are often prescribed with their labels removed. And paternalism is sanctioned by the courts. In 1995 the Japanese Supreme Court ruled that physicians are not obliged to inform cancer patients of the nature of their condition, upholding earlier rulings by district and high courts.

Truth telling in Lebanon demonstrates a transition from a tradition of paternalism to a modern embrace of the principle of patient autonomy in developed countries. There are several interesting findings in a 1999 survey of 498 patients with terminal cancer in Lebanon[iii]. In this survey the majority of physicians stated they would opt for what is thought to be the culturally accepted norm, viz. withholding disclosure of a terminal illness from the patient and rather telling the family. However, the majority of patients prefer disclosure. The same survey found that patient preference for disclosure of a cancer diagnosis correlates highly with younger age, better education and better professional achievement. The attitude toward truth telling in Lebanon suggests a transition from the long tradition of physician paternalism in many cultures to the modern embrace of patient autonomy.

Preference for concealment appears to be the prevalent attitude in traditional cultures where paternalistic-beneficent attitudes of physicians predominate over respect for the autonomy rights of patients. A crucial factor responsible for the transition from paternalism to autonomy is education. People who have little access to information have a rudimentary understanding of an illness, its treatment, diagnosis and prognosis. However, when people become educated and have access to good information, they become more aware of the scientific basis of the illness and the limits of modern medicine. And as people become more educated, they refuse to accept the authority of paternalism. They prefer to make decisions for themselves and assert their autonomy.

In the United States, ethical issues in medicine have evolved around the principle of patient autonomy. This principle asserts the rights of patients to be informed of their diagnosis, prognosis and the risks and benefits of therapies, and to be allowed to make informed decisions about treatments and withholding resuscitation. In the United States autonomy has become a moral absolute. In this respect, Pellegrino[iv] lists several reasons, including improved education of the public, a strong tradition of privacy rights and personal liberty, a distrust of authority, the possibilities of medical technology and the loosening of family and community identification in the United States. Pellegrino then proposes that the fundamental issue in the controversy over truth telling is not a culturally bound phenomenon, but a universal phenomenon of conflict between traditional values and the contemporary Anglo-American concept of autonomy. This may be true but it’s important to highlight the importance of education in the transition from paternalism which is dominant in traditional cultures to autonomy which has trumped beneficence in modern cultures.

Back to our case study, was the daughter right to urge the doctor to withhold the diagnosis of terminal cancer from her mom because she feared that the bad news would destroy her? And is their Chinese heritage an important factor in truth telling? As we discussed above, in the traditional agrarian Chinese culture it was common practice for families to shield their loved ones from learning of a terminal diagnosis, and indeed the patient prefers they do so. In traditional Chinese culture patients expected that family members would make healthcare decisions for them.

As we discussed in our August 2009 blog, there are two main situations in which it is justified to withhold the truth from a patient: (1) if the physician has compelling evidence that disclosure will cause real and predictable harm or (2) if the patient states an informed preference not to be told the truth. In our case study it would be difficult to fault the daughter who wants to withhold the bad news from her mother since that position is common practice in agrarian China. In that tradition a family shields their loved one from the shock of a terminal diagnosis and indeed the loved one prefers not to be told. Thus the daughter has compelling cultural evidence that disclosure would cause real and predictable harm to her mother and that her mother would prefer not to be told the truth. Thus her request to the physician may be justifiable.

Would the physician be right to comply with the daughter’s request? As we discussed the principle of patient autonomy usually trumps paternalism in American culture. From the physician’s perspective he has no clear evidence of predictable harm and he does not have the patient’s informed consent not to be told the truth. Yet if he learns of the Chinese agrarian tradition, he would be sympathetic to the daughter’s request. Clearly he should take the time to have a serious discussion with the daughter. He should evaluate suicide risk. If the mother has a history of serious depression and the daughter strongly suspects that the bad news would put her mother in real jeopardy of suicide, he would have reason to withhold the truth from his patient. Barring suicide risk he may want to present some reasons why disclosure may help her mother. Above all, he should stress that the impact of the truth on patients depends largely on how it is told. There is no need to be blunt. Patient autonomy can be served by offering the patient “the opportunity to learn the truth, at whatever level of detail the patient desires”[v].


[i] Side Li & Ha-Ling Chou. Communication with the cancer patient in China, Annals of the New York Academy of Sciences, 1997; 809: 243-248

[ii] Yosuke Uchitomi & Shigeto Yamawaki. Truth-telling practice in cancer care in Japan, Annals of the New York Academy of Sciences, 1997; 809: 290-299

[iii] Salim M. Adib & Ghassan N. Hamadek, Attitudes of the Lebanese public regarding disclosure of serious illness, Journal of Medical Ethics, 1999; 25: 399-403

[iv] Edmund Pellegrino, Is truth telling to patients a cultural artifact?, Journal of the American Medical Association, 1992; 268: 1734-5

[v] Benjamin Freedman “Offering the Truth: One Ethical Approach to the Uninformed Cancer Patient”, Archives of Internal Medicine 153 (8 March 1993), 572-76

Undue Burden?

The Vatican & Artificial Nutrition & Hydration

Consortium of Jesuit Bioethics Programs


Most Americans know the case of Terri Schiavo, the Florida woman who suffered cardiac arrest and subsequently lived for years in a persistent vegetative state while moral, legal, and political wrangles over her care divided her family and roiled the nation.

The Schiavo case highlighted the medical practice of providing artificial nutrition and hydration (ANH) to patients who can no longer swallow food or eat sufficiently well to sustain health or life. In the process, it prompted concern among many Catholic bishops, both in the United States and the Vatican, that ANH might be withdrawn from patients with the intention either of euthanasia or of ending a life that some people deem unworthy of further medical care. In July 2007, seven directors of bioethics programs at Jesuit universities came together to form the Consortium of Jesuit Bioethics Programs, dedicated to informing and influencing medical-ethical debates within the Catholic Church and the larger society. As one of our first outreach tasks, our consortium decided to address the subject of ANH.

First, some background on recent and pending church teachings concerning artificial nutrition and hydration. In 2004, John Paul II delivered an allocution on the use of ANH for patients in a persistent vegetative state (PVS). We strongly affirm his stance that all of human life deserves respect, and that health-care workers should not unilaterally deny patients treatments based on their own judgments of quality of life. However, the pope’s statement included some assertions that surprised many involved in health care. One was that ANH “always represents a natural means of preserving life, not a medical act,” and thus should be considered “morally obligatory.” The pope stated furthermore that “no evaluation of costs can outweigh the value of the fundamental good which we are trying to protect, that of human life,” and added that “society must allot sufficient resources for the care of this sort of frailty.”

Some theologians believe these statements represent a departure from long-standing Roman Catholic bioethical traditions. The current U.S. Conference of Catholic Bishops’ Ethical and Religious Directives for Catholic Health Care Services (fourth edition, 2001)—which guide all Catholic-sponsored health care in the United States-state that “a person may forgo extraordinary or disproportionate means of preserving life,” and define such means as “those that in the patient’s judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.” The bishops’ directives would appear not to align with John Paul’s 2004 allocution in two important ways. First is their insistence that the decision of whether a “means” or treatment is ordinary (and thus obligatory) or extraordinary (and not obligatory) is based on the patient’s judgment of that treatment’s benefits and burdens. In contrast, the papal allocution defines ANH as ordinary and obligatory—regardless of the patient’s judgment. Second, the Ethical and Religious Directives state that such a judgment may take into consideration a treatment’s financial burdens to the patient, the patient’s family, or the community; the papal statement, on the other hand, seems to prohibit such considerations.

Subsequent statements by the Congregation for the Doctrine of the Faith (CDF) and the Vatican have seemed to uphold a stringent reading of the pope’s statement. A Vatican commentary on the CDF’s response listed just three conditions when ANH might not be morally obligatory: (1) when it would be impossible to provide; (2) when a patient may be unable to assimilate food and liquids; and (3) when ANH may be excessively burdensome for the patient or may cause significant physical discomfort, for example resulting from complications in the use of the means employed.

Catholics both within and without the health-care system are left with uncertainty about how to apply John Paul II’s allocution. While the pope’s statement referred specifically to the provision of ANH to patients like Terri Schiavo, who are declared permanently unconscious, some health-care workers worry about more general applications, for example, to patients with advanced Alzheimer’s disease. Perhaps of most concern to those who work with gravely ill persons is a recent article by Bishop William E. Lori and Cardinal Justin Rigali (America, October 13, 2008), arguing that not everything in the CDF’s “Responses” applies solely to patients in a persistent vegetative state, and specifically that ANH should be offered to patients with chronic but stable debilitating conditions less extreme than PVS. In June 2008, at the annual meeting of the U.S. bishops, Bishop Lori and Cardinal Rigali convinced the bishops to begin a process of amending the Ethical and Religious Directives, potentially extending recent teachings to new patient populations. The bishops may vote on these changes as early as June 2009.

In light of these ongoing actions, we offer some important facts and recommendations that might inform deliberations about artificial nutrition and hydration.

Though John Paul II explicitly maintains that providing ANH is not a medical act, the reality is that within the fields of medicine and law, the practice generally is viewed as a medical treatment. The most common way of administering ANH, through an endoscopic gastrostomy or PEG tube, involves a surgical procedure that requires both an anesthesiologist and a gastroenterologist, who inserts an endoscope through the mouth and esophagus into the stomach, then surgically opens the stomach to pass the tube through to the exterior of the body. Every patient with a tube requires skilled nursing care provided by a professional or by trained family members, frequent laboratory tests, and careful physician supervision, as the tubes have medical complications, including the possibility of life-threatening infections or even death.

Health-care costs associated with tube feedings are significant. Excluding the initial cost of surgery and the costs of caring for complications, which can be very high, health-care literature from 2007-09 estimates the annual cost of caring for a PEG tube at home to range from $9,000 to $25,000. However, many families cannot afford to take time away from their jobs to provide the necessary home care. At approximately $60,000 per year, the cost of putting a patient with a PEG tube in a skilled nursing facility is also out of reach for many families.

From a legal point of view, while many state statutes set a stringent standard for the refusal of ANH, a 2002 review of statutory and case law published in the Journal of the American Geriatrics Society concluded that case law supports a “consensus that ANH is a medical treatment that can be forgone like any other treatment.” In theory, and consistent with well-established professional norms requiring informed consent for medical interventions, a hospital that forced ANH on a patient who legally refused it could be accused of battery.

Without a doubt, ANH can benefit many patients. In cases of acute illness or trauma, the practice can provide support while patients heal; and in chronic and some terminal illnesses, it can extend life. Some patients in PVS or patients who suffer a stroke may live years longer with ANH than without it. Nevertheless, some who receive ANH do not clearly benefit. For example, persons with advanced dementia who receive tube feeding have the same life expectancy as those fed by hand. Similarly, several studies involving patients dying of cancer indicate that their life expectancy is not prolonged by ANH. We urge physicians to practice evidence-based medicine and to start ANH only when data indicate a reasonable hope of benefit.

We believe that when ANH is used inappropriately, as might be the case with many advanced dementia patients, such patients are denied the care they deserve. Feeding by hand puts the dying person in contact with caregivers and provides the tenderness of human contact. Hand-fed patients are also no more likely to experience aspiration pneumonia caused by inhaling food. In our view, tube feeding implemented for convenience, or to assuage the sensibilities of family, or for cosmetic reasons, is inappropriate. Although hand feeding takes more time, we urge families and health-care workers to provide hand feeding as an alternative to ANH whenever nutritional needs can be met equally well in this manner.

We believe that ANH should be started whenever the likely benefits to a patient outweigh its burdens. However, the fact is that if patients or physicians in Catholic hospitals fear that ANH cannot be discontinued once it is started, then some physicians will be less likely to offer the option, even when it might be appropriate to do so as a short-term trial. Thus, patients, families, physicians, and nurses must be reassured by Catholic facilities that health care will not be provided without informed consent.

It is important to note that before the relatively recent development of ANH technologies, all patients who lost the ability to swallow—usually due to profound brain damage—died. While ANH may delay death in some cases, in many others the dying process will continue unabated. So while the denial of treatment for patients based on health-care workers’ quality-of-life judgments remains a legitimate concern, so too do overtreatment and the failure to accept that some conditions, such as advanced Alzheimer’s disease, are terminal and will cause death. As ethicists working in health care, we understand that both situations cause moral distress for physicians, nurses, social workers, and other care providers. Emotional and mental anguish can result from the inability to perform what one believes to be the appropriate moral action. This in turn contributes to burnout and a decreased quality of patient care. We recommend that the voice of health-care workers be heard throughout the current discernment process in the church and in specific cases of clinical decision making.

We wish to warn against making hasty generalizations from recent Catholic teaching on the use of ANH with patients in a relatively stable persistent vegetative state. Other patients’ conditions and circumstances may differ significantly, and most decisions regarding medical intervention versus a focus on comfort care are made in far more ambiguous contexts, in which the best plan of care is not always obvious. Families typically wish to err on the side of “giving the patient every chance,” but they seldom wish to put the patient through pain and suffering if little hope of recovery exists. And so they work with the health-care team to determine a plan of care that has a reasonable chance of benefiting the patient. It is important that we not preempt the good-faith efforts of families to discern which treatments are in the best interest of the patient and which are simply not worth inflicting. The Catholic tradition has generally manifested a healthy respect for the judgment of patients and their families in these situations.

As a general rule, health-care workers, families, and the magisterium all want what is in the best interest of patients. Discerning precisely what that is requires a conscience formed both by general principles provided by our Catholic tradition and by the concrete facts of a patient’s circumstances and experiences. We believe that the current edition of the Ethical and Religious Directives properly acknowledges the importance both of long-standing principles and of individual discernment-and we hope that as the U.S. bishops consider revising specific directives, they will preserve that balance.


ABOUT THE WRITER

Consortium of Jesuit Bioethics Programs

Consortium of Jesuit Bioethics Programs: Mark Aita, SJ; Debra Bennett-Woods; Peter Clark, SJ; James M. DuBois; Amy Haddad; Mark Kuczewski; Carol Taylor; and James J. Walter. Further information on the authors, the Consortium, and artificial hydration and nutrition can be found at www.jesuitbioethics.net.