Truth-Telling in Medicine

Question:  Should doctors always tell the truth to their patients? There is an ongoing debate among physicians, families and patients on this issue. The debates are complex but they usually come down to disagreements about the limits of paternalism and the proper balance between the principles of autonomy and beneficience.

The principle of nonmalficence – the duty to do no harm – and the principle of beneficience – the duty to act for the benefit of others – have ancient roots in the code of medical ethics. But truthfulness does not. The Hippocratic Oath does not mention an obligation of truth-telling or disclosure, and until 1980 even the professional code of the American Medical Association did not say anything about dealing honestly with patients. Over the years physicians viewed the truth as something to conceal or reveal in so far as it impacts the therapeutic welfare of the patient. For example, a physician might be reluctant to disclose the diagnosis of cancer to a vulnerable patient if he judges that the truth would be harmful, unsettling and depressing. This paternalistic approach – doctor knows best – is less common today. Now there is more of an emphasis on the principle of autonomy and informed consent.

Contrary to what many physicians have thought in the past, a number of studies have demonstrated that patients do want their physicians to tell them the truth about diagnosis, prognosis, and therapy. For instance, 90% of patients surveyed said they would want to be told of a diagnosis of cancer or Alzheimer’s disease. Similarly, a number of studies of physician attitudes reveal support for truthful disclosure. For example, whereas in 1961 only 10% of physicians surveyed believed it was correct to tell a patient of a fatal cancer diagnosis, by 1979 97% felt that such disclosure was correct.

When physicians communicate with patients, being honest is an important way to foster trust and show respect for the patient. Patients place a great deal of trust in their physician, and may feel that trust is misplaced if they discover or perceive lack of honesty and candor by the physician.

In addition to fostering trust and demonstrating respect, giving patients truthful information helps them to become informed participants in important health care decision. Thus, patients should be told all relevant aspects of their illness, including the nature of the illness itself, expected outcomes with a reasonable range of treatment alternatives, risks and benefits of treatment, and other information deemed relevant to that patient’s personal values and needs. Treatment alternatives that are not medically indicated or appropriate need not be revealed. Facts that are not important to the patients ability to be an informed participant in decision making, such as results of specific lab tests, need not be told to the patient. Also, complete and truthful disclosure need not be brutal; appropriate sensitivity to the patient’s ability to digest complicated or bad news is important.

There are two main situations in which it is justified to withhold the truth from a patient. As noted above, if the physicians has compelling evidence that disclosure will cause real and predictable harm, truthful disclosure may be withheld. Examples might include disclosure that would make a depressed patient actively suicidal. This judgment, often referred to as the therapeutic privilege, is important but also subject to abuse. Hence it is important to invoke this only in those instances when the harm seems very likely, not merely hypothetical.

The second circumstance is if the patient states an informed preference not to be told the truth. For instance, some patients might ask that the physician instead consult family members. In these cases, it is critical that the patient give thought to the implications of abdicating their role in decision making. If they chose to make an informed decision not to be informed, however, this preference should be respected.

What is a Do Not Resuscitate (DNR) Order?

A DNR order is a medical order issued by a physician or other authorized practitioner that directs healthcare providers not to administer CPR (Cardio Pulmonary Resuscitation) in the event of cardiac or respiratory arrest. A DNR order may be written in the absence of a living will or the conditions that would make a living will operative. A living will may contain a provision indicating that a patient does not desire CPR. However, if a patient’s preference to forgo CPR is expressed only in a living will, CPR will be withheld only when a physician has determined that the patient is not competent and has certified in writing that the patient has an end-stage medical condition or is permanently unconscious.1 Without such physician determination and certification or without a DNR order, the patient’s expressed preference for withholding CPR is not sufficient.2 In order for a patient’s preferences to be carried out, patients, families, and healthcare providers must understand the distinction between the circumstances under which a living will and a DNR order are applicable.
A DNR order is not subject to the preconditions imposed by the Living Will Act. A DNR order becomes operative only in the narrow context of cardiac or respiratory arrest regardless of the precipitating clinical event and does not preclude otherwise appropriate treatments or life-sustaining interventions.2,7 Misinterpretation of DNR orders was demonstrated by a survey conducted in an outpatient cancer center, which showed that only 34% of the patients correctly understood the meaning of a DNR order; 66% of the patients did not realize that a DNR order would result in not being resuscitated even if the cause of the cardiac or respiratory arrest was potentially reversible.8
In June of 2002 Pennsylvania enacted the Do-Not-Resuscitate Act (DNR Act) (P.L. 409, No. 59) (20 Pa.C.S. §§ 54A01-54A13). The DNR Act empowered a terminally ill person or the person’s surrogate to secure an out-of-hospital do-not-resuscitate order and, at the person’s option or the option of an authorized representative, an out-of-hospital DNR bracelet or necklace. These items direct emergency medical services (EMS) personnel in the out-of-hospital setting not to provide the person for whom they are issued with cardiopulmonary resuscitation in the event of the person’s cardiac or respiratory arrest. The DNR Act also specified the circumstances under which an appropriate representative of a person who issued a declaration under the Advance Declaration for Health Care Act (former Living Will Act) would be able to secure an out-of-hospital DNR order, bracelet or necklace for the person if the person became permanently unconscious. These provisions, supplemented by Department of Health regulations (28 Pa. Code §§ 1051.1-1051.101), went into effect March 1, 2003, and were amended February 7, 2004.

Specifically, an out-of-hospital DNR order is a written order that is issued by a person’s attending physician that directs EMS providers to withhold CPR from the person in the event of that person’s cardiac or respiratory arrest. Thus, if an ambulance is called to attend to a person for whom an out-of-hospital DNR order has been issued and the ambulance crew observes the out-of-hospital DNR order with original signatures with the person, or observes that the person is wearing an out-of-hospital DNR bracelet or necklace, the ambulance crew will not attempt CPR unless it is appropriately communicated to a member of the crew that the out-of-hospital DNR order has been revoked.

Definitions:
1. Cardio-Pulmonary Resuscitation (CPR): refers to the medical procedures used to restart a person’s heart and breathing when the person suffers cardiac or respiratory arrest. CPR may involve simple efforts such as mouth-to-mouth resuscitation and external chest compression. Advanced CPR may involve insertion of a tube to open the person’s airway or to assist breathing, injection of medications, or providing an electrical shock (defibrillation) to resuscitate the heart.
2. End-Stage Medical Condition: An “end-stage medical condition” is an incurable and irreversible medical condition in an advanced state caused by injury, disease, or physical illness that will, in the opinion of the attending physician, to a reasonable degree of medical certainty, result in death, despite the introduction or continuation of medical treatment. If a patient having an end-stage medical condition serves as the reason for which an out-of-hospital DNR order is sought for that patient, the attending physician must make the determination that the patient has an end-stage medical condition before the physician may issue an out-of-hospital DNR order for the patient. All persons who are in a terminal condition have an end-stage medical condition.
3. Permanently Unconscious: “Permanently unconscious” is a medical condition that has been diagnosed in accordance with currently accepted medical standards and with reasonable medical certainty as total and irreversible loss of consciousness and capacity for interaction with the environment. The term includes, without limitation, a persistent vegetative state or irreversible coma. If a patient being permanently unconscious serves as the reason for which an out-of-hospital DNR order is sought for the patient, the attending physician must make the determination that the patient is permanently unconscious and the patient must have previously executed a living will which provides that no CPR be administered in the event of the person’s cardiac or respiratory arrest if the person becomes permanently unconscious, or authorizes a surrogate or other authorized representative of the person to make that decision under those circumstances.
4. Emergency Medical Services (EMS) Provider: EMS providers are individuals licensed, certified, recognized, or otherwise authorized under the Emergency Medical Services Act (35 P.S. §§ 6921-6934) to provide medical care on an emergency, out-of-hospital basis. They are most frequently associated with ambulance services. EMS personnel who administer emergency treatment include EMTs (emergency medical technicians), EMT-paramedics (paramedics), prehospital registered nurses, ambulance attendants, first responders and health professional physicians. EMS providers also include individuals given good Samaritan civil immunity protection under Pennsylvania law (42 Pa.C.S. § 8331.2) when using an automated external defibrillator. Physicians who provide medical command to EMS personnel must also honor an out-of-hospital DNR order when appraised of it by EMS personnel.
5. Attending Physician: An attending physician is a physician who has primary responsibility for the treatment and care of the person. More than one physician may have primary responsibility for the medical care and treatment of a person. A physician who is requested to issue an out-of-hospital DNR order for a person needs to make a good faith judgment as to whether the physician is an attending physician of the person based upon the medical care the physician provides to the person. If the physician determines that the circumstances of the physician-patient relationship do not enable the physician to determine whether he or she qualifies as the patient’s attending physician, the physician will attempt to supplement that knowledge with information the physician secures after making reasonable inquiries of the person or the person’s surrogate or other authorized representative regarding the medical care the person is receiving from other physicians.
6. Surrogate: For purposes of the repealed DNR Act and the regulations that were adopted pursuant to that act, a surrogate is an individual who has, or individuals who collectively have, legal authority to request an out-of-hospital DNR order for another person or to revoke that order. Under the Act the term “surrogate” is limited to a health care agent or health care representative as those terms are defined in the Health Care Agents and Representatives Act (20 Pa.C.S. §§ 5451-5465). This does not include all persons who fall under the former definition of “surrogate.” However, the Act permits persons other than surrogates, by virtue of their special relationship to the person for whom an out-of hospital DNR order is sought, to also make a request for an out-of-hospital DNR order for that person. An example of such a person is a parent of a child who has an end-stage medical condition who is under 18 years of age and who is not emancipated, who has not graduated high school or been married, and who does not have a court-appointed guardian. Yet another example is a court-appointed guardian for an adult who has an end-stage medical condition and who the court concludes is unable to meet essential requirements for his or her physical health or safety because the person does not have the ability to receive and evaluate relevant information effectively or communicate relevant decisions. However, other than when a person is relying upon the definition of “surrogate” in the Act to qualify to ask for an out-of-hospital DNR order for another person, the focus should be on whether that person, by virtue of a special relationship to the person for whom the out-of-hospital DNR order is sought, has legal authority to request an out-of-hospital DNR order for that person. We encourage you to seek the advice of an attorney if you have a question regarding who can serve as a surrogate or other authorized representative for another person to request an out-of-hospital DNR order for that person.

What is an Advance Directive? Are there particular laws regarding advance directives in Pennsylvania?

Advance directives are documents which indicated your health care wishes in the event that you are not capable of making your own decisions. Advance directives are not used for decision-making if the patient is able to make the decision.

Pennsylvania recognizes two types of advance directives, durable power of attorney for health care decisions and living wills. A Values History is another form of advance directive (which may or may not include a living will and durable power of attorney for health care decisions). Here is a link to a sample Values History form. The AbioCor Implantable Heart Trial required all research participants to fill out a Values History Form.

Here is a link to the AMA’s public web-site for advance directives. It includes samples of a living will and DPA form. Pennsylvania does not require these forms to be notarized. But since some states do, the forms include a line for notarization as well. http://www.ama-assn.org/public/booklets/livgwill.htm

Durable Power of Attorney for Health Care Decisions (DPA) – This is a document indicating the patient’s choice of surrogate in the event that the patient loses decisional capacity. It must be filled out by the patient while he/she has intact decisional capacity. In many states, including Pennsylvania, it must also be signed by the designated surrogate. This is also referred to as “health care proxy” or “designated surrogate.” Designating a DPA helps moderate disagreements among family members and clarify who makes the decisions for the patient. Without such a document, there can be confusion over who should make decisions for the patient. In the absence of a DPA, many institutions will choose the next of kin to be the surrogate decision-maker for a patient who lacks the capacity to make his/her own decisions. DPA is essential if the person you wish to make decisions for you is not your next of kin or if you do not have any close relatives (for example, a parent might be chosen over a live-in partner, or an individual’s spouse might be chosen even though the couple had been separated).

Living Will – This is “a document executed by an adult which indicates his or her preferences regarding the initiation, continuation, withholding, or withdrawing of medical treatment in the event that he or she loses decision-making capacity.” (Ibid.) This helps the surrogate make decisions for the patient. It also promotes the patient’s actual wishes instead of someone else’s. Few people write living wills. It is difficult to anticipate future medical situations and what you might want at that time. However, these decisions are always difficult. Living wills provide support to loved ones by guiding them in your wishes and relieving some of their burden.

Under the federal Patient Self Determination Act, all health care institutions receiving Medicare or Medicaid funding:

1. must provide written information regarding his or her rights under state law to make decisions concerning medical care, including advance directives, to each adult receiving medical care through the provider or organization.

2. cannot condition the provision of care or discriminate against an individual based on whether or not the individual has executed an advance directive.

3. must comply with patients’ advance directives in a way that is consistent with state law.

4. must note patients’ records whether or not they have advance directives.

5. provide education about advance directives. (PSDA Interim Final Rule, 57 Federal Register 8194-8204 [3/06/96]).

Pennsylvania’s Advance Directive for Health Care Act, allows an individual of sound mind who is 18 years or older (or has graduated from high school or is married) to execute an advance directive. It also includes the following:

1. There is civil and criminal immunity for health care providers who follow the procedures set forth in the act.

2. There is no specific format for the advance directive.

3. The advance directive does not need to be notarized, but must be signed by the declarant or another on behalf of the declarant and witnessed by two adults.

4. The advance directive becomes operative when “a copy is provided to the attending physician and the declarant is determined by the attending physician to be incompetent and in a terminal condition or in a state of permanent unconsciousness.” These prognoses must be confirmed by a second physician.

5. An advance directive can be revoked at any time and in any manner by the declarant regardless of his/her mental or physical condition. The revocation is effective upon communication to any health care provider by the declarant or a witness to the revocation.

6. Artificial nutrition and hydration are identified as forms of life-sustaining treatment and thus, may be withdrawn if requested by the patient in the advance directive.

7. Health care providers who feel morally unwilling to comply with the patient’s advance directive can transfer care to another qualified health care provider who will comply if possible. But, if this is not feasible the health care provider must comply with the patient’s advance directive.

8. Any pregnant woman who is incompetent and either terminally ill or permanently unconscious must be maintained on life support until the fetus can be safely delivered. However, there is no requirement to perform a pregnancy test.

There are three exceptions to this requirement. They hold if the attending physician and an obstetrician after an examination believe that…

1. life-sustaining treatment, nutrition, and hydration would not result in the development and live birth of the fetus;

2. such treatment would be harmful to the woman;

or

3. the treatment would cause her pain that medication could not alleviate.

Under such circumstances, the living will can be followed.

9. The medical command physician may authorize emergency medical personnel to honor an advance directive. The medical command physician may base this decision on prior notification that a valid and operative advance directive exists or the notification by emergency medical services personnel that they have been presented with a signed, advance directive. Emergency medical services personnel must immediately notify the medical command physician when presented with a living will, signed by the patient, or other authorized person.

10. “Emergency medical services personnel confronted with any conflicting information regarding the patient’s wishes for life-sustaining treatment shall act according to the accepted treatment protocols and standards appropriate to their level of certification.( 5413)”

(Advance Directive for Health Care Act, 1992, April 16, P.L. 108, No. 24, 5402-5501)

 

Particular Questions about Advance Directives:

1. When will my living will take effect?

Your living will takes effect when the following three conditions are met:

(a) Your physician or health care provider has a copy of your living will;

(b) Your physician has determined that you are incompetent; and

(c) Your physician has determined that you are permanently unconscious or suffer from an end-stage medical condition.

2. What does it mean to be incompetent?

To be incompetent means that you are unable to understand the risks and benefits of a medical decision, you cannot make a medical decision on your behalf, or you cannot communicate a medical decision to your health care provider. For example, if you are unconscious or you suffer from dementia, your health care provider likely will determine that you are incompetent. A formal adjudication of incompetency by a court is not required for your living will to take effect. Back to top

3. What is an end-stage medical condition?

An end-stage medical condition is an incurable or irreversible medical condition in an advanced state that even with the introduction of medical treatment will result in death. For example, advanced Alzheimer’s disease or terminal cancers are considered end-stage medical conditions.

4. Does my health care provider have to follow the instructions in my living will?

Generally, yes. Pennsylvania law requires health care providers to follow the instructions in your living will. However, there are special rules about pregnant women who have living wills. Also, a living will cannot instruct your health care provider to act contrary to Pennsylvania law. If your health care provider cannot follow your instructions because of moral beliefs, your health care provider must transfer your care to another health care provider who can follow your instructions.

5. What is a health care power of attorney?

A health care power of attorney allows you to appoint someone to make medical decisions for you should you be unable to make medical decisions for yourself. You can also provide instructions to help your appointed decision maker make medical decisions. Back to top

6. When does a health care power of attorney take effect?

A health care power attorney takes effect when the following two conditions are met:

(a) Your health care provider has a copy of your health care power of attorney; and

(b) Your health care provider determines that you are incompetent.

7. What is a health care representative?

A health care representative is a person authorized by Act 169 of 2006 to make medical decisions for you if you do not have an advance directive and your physician determines that you are incompetent.

8. What medical decisions can my health care representative make?

Generally, the medical decisions your health care representative can make are the same as the decisions an appointed decision maker can make under a health care power of attorney. That means your health care representative can consent to surgery, authorize your admission to a nursing home, access your medical records, and consent to donation of your organs.

9. Who can be my health care representative?

Act 169 of 2006 provides a list of persons who can serve as your health care representative. The following persons, in the order listed, can be your health care representative:

(a) Spouse and, if applicable, your adult children from a prior relationship;

(b) Adult children;

(c) Parents;

(d) Adult siblings;

(e) Adult grandchildren; and

(f) Any adult who has knowledge of your values and beliefs (e.g. close friend, cousin, roommate)

10. Can I have more than one health care representative?

Yes. All members of the same class can act as your health care representative. For example, if you do not have a current spouse, but you have three adult children, all three adult children can act as your health care representative.

11. What if my health care representatives cannot agree to a decision regarding my care?

Act 169 of 2006 allows health care providers to follow the instructions of the majority of your health care representatives. For example, if you have three adult children who are acting as your health care representative and they cannot agree on a medical decision, the health care provider will follow the majority decision.

12. What are the main differences between a living will and a health care power of attorney?

A living will and health care power of attorney serve different functions. First, a living will is more limited in scope than a health care power of attorney. A living will only applies to medical care and decisions regarding end-of-life care. A health care power of attorney is broader in scope as it applies to all medical care and treatment. Second, a health care power of attorney allows you to appoint a decision maker to make medical decisions on your behalf. A living will generally does not appoint anyone to make medical decisions for you. Rather, you provide instructions to your health care provider regarding end-of-life care. Third, a health care power of attorney takes effect when you are incompetent while a living will does not take effect until you are both incompetent and permanently unconscious or suffer from an end-stage medical condition.

13. Does Pennsylvania recognize advance directives from other states?

Generally, yes. As long as the instructions in your advance directive are not contrary to Pennsylvania law, your advance directive from another state is valid in Pennsylvania.

14. Do other states recognize advance directives from Pennsylvania?

Likely, yes. However, you should check the law of the other state to be sure that the state recognizes out of state advance directives.

15. Is a health care power of attorney the same as a financial power of attorney?

No. A health care power of attorney is specifically limited to medical care and treatment. Typically, a financial power of attorney does not authorize the appointed individual to make medical decisions.

16. Where can I get more information regarding advance directives?

If you are admitted to Lancaster General Hospital, LGH staff can provide you with more information. Also, to following organizations are available for you to contact:

Pennsylvania Department of Aging

555 Walnut Street, 5th Floor

Harrisburg, PA 17101-1919

(717) 783-6842

http://www.aging.state.pa.us/

 

Pennsylvania Medical Society

777 East Park Drive

P.O. Box 8820

Harrisburg, PA 17105-8820

1-800-228-7823

http://www.pamedsoc.org/

 

Aging with Dignity

P.O. Box 1661

Tallahassee, FL 32302-1661

(888) 594-7437

http://www.agingwithdignity.org/

 

What is the Catholic Church’s position on Reiki as an alternative therapy?

The Committee on Doctrine of the United States Conference of Catholic Bishops issued a document entitled: “Guidelines For Evaluating Reiki As An Alternative Therapy” on March 25, 2009. The following is their position:

 

GUIDELINES FOR EVALUATING REIKI AS AN ALTERNATIVE THERAPY

 

Committee on Doctrine

United States Conference of Catholic Bishops

25 March 2009

 

1. From time to time questions have been raised about various alternative therapies that areoften available in the United States. Bishops are sometimes asked, “What is the Church’s

position on such therapies?” The USCCB Committee on Doctrine has prepared this resource inorder to assist bishops in their responses.

 

I.                   HEALING BY DIVINE GRACE AND HEALING BY NATURAL POWERS

 

2. The Church recognizes two kinds of healing: healing by divine grace and healing thatutilizes the powers of nature. As for the first, we can point to the ministry of Christ, who

performed many physical healings and who commissioned his disciples to carry on that work. In fidelity to this commission, from the time of the Apostles the Church has interceded on behalf of

the sick through the invocation of the name of the Lord Jesus, asking for healing through the power of the Holy Spirit, whether in the form of the sacramental laying on of hands and

anointing with oil or of simple prayers for healing, which often include an appeal to the saints for their aid. As for the second, the Church has never considered a plea for divine healing, which

comes as a gift from God, to exclude recourse to natural means of healing through the practice of medicine.[i] Alongside her sacrament of healing and various prayers for healing, the Church has a

long history of caring for the sick through the use of natural means. The most obvious sign of this is the great number of Catholic hospitals that are found throughout our country.

 

3. The two kinds of healing are not mutually exclusive. Because it is possible to be healed by divine power does not mean that we should not use natural means at our disposal. It is not

our decision whether or not God will heal someone by supernatural means. As the Catechism of the Catholic Church points out, the Holy Spirit sometimes gives to certain human beings “a

special charism of healing so as to make manifest the power of the grace of the risen Lord.”[ii]This power of healing is not at human disposal, however, for “even the most intense prayers do

not always obtain the healing of all illnesses.”[iii] Recourse to natural means of healing therefore remains entirely appropriate, as these are at human disposal. In fact, Christian charity demands

that we not neglect natural means of healing people who are ill.

 

II.                REIKI AND HEALING

 

A)    The Origins and Basic Characteristics of Reiki

 

4. Reiki is a technique of healing that was invented in Japan in the late 1800s by MikaoUsui, who was studying Buddhist texts.[iv] According to Reiki teaching, illness is caused by some

kind of disruption or
imbalance in one’s “life energy.” A Reiki practitioner effects healing by placing his or her hands in certain positions on the patient’s body in order to facilitate the flow of
 

 

Reiki, the “universal life energy,” from the Reiki practitioner to the patient. There are numerous designated hand positions for addressing different problems. Reiki proponents assert that the

practitioner is not the source of the healing energy, but merely a channel for it.[v] To become a Reiki practitioner, one must receive an “initiation” or “attunement” from a Reiki Master. This

ceremony makes one “attuned” to the “universal life energy” and enables one to serve as a conduit for it. There are said to be three different levels of attunement (some teach that there are

four). At the higher levels, one can allegedly channel Reiki energy and effect healings at a distance, without physical contact.

 

B)    Reiki as a Natural Means of Healing

 

5. Although Reiki proponents seem to agree that Reiki does not represent a religion of its own, but a technique that may be utilized by people from many religious traditions, it does have

several aspects of a religion. Reiki is frequently described as a “spiritual” kind of healing a opposed to the common medical procedures of healing using physical means. Much of the

literature on Reiki is filled with references to God, the Goddess, the “divine healing power,” and the “divine mind.” The life force energy is described as being directed by God, the “Higher

Intelligence,” or the “divine consciousness.” Likewise, the various “attunements” which the Reiki practitioner receives from a Reiki Master are accomplished through “sacred ceremonies”

that involve the manifestation and contemplation of certain “sacred symbols” (which have traditionally been kept secret by Reiki Masters). Furthermore, Reiki is frequently described as a

“way of living,” with a list of five “Reiki Precepts” stipulating proper ethical conduct.

 

6. Nevertheless, there are some Reiki practitioners, primarily nurses, who attempt to approach Reiki simply as a natural means of healing. Viewed as natural means of healing,

however, Reiki becomes subject to the standards of natural science. It is true that there may be means of natural healing that have not yet been understood or recognized by science. The basic

criteria for judging whether or not one should entrust oneself to any particular natural means of healing, however, remain those of science.

 

7. Judged according to these standards, Reiki lacks scientific credibility. It has not been accepted by the scientific and medical communities as an effective therapy. Reputable scientific

studies attesting to the efficacy of Reiki are lacking, as is a plausible scientific explanation as to how it could possibly be efficacious. The explanation of the efficacy of Reiki depends entirely

on a particular view of the world as permeated by this “universal life energy” (Reiki) that is subject to manipulation by human thought and will. Reiki practitioners claim that their training

allows one to channel the “universal life energy” that is present in all things. This “universal life energy,” however, is unknown to natural science. As the presence of such energy has not been

observed by means of natural science, the justification for these therapies necessarily must comefrom something other than science.

 

C)    Reiki and the Healing Power of Christ

 

8. Some people have attempted to identify Reiki with the divine healing known to Christians.[vi] They are mistaken. The radical difference can be immediately seen in the fact that

for the Reiki practitioner the healing power is at human disposal. Some teachers want to avoid this implication and argue that it is not the Reiki practitioner personally who effects the healing,

but the Reiki energy directed by the divine consciousness. Nevertheless, the fact remains that for Christians the access to divine healing is by prayer to Christ as Lord and Savior, while the

essence of Reiki is not a prayer but a technique that is passed down from the “Reiki Master” to the pupil, a technique that once mastered will reliably produce the anticipated results.[vii] Some

practitioners attempt to Christianize Reiki by adding a prayer to Christ, but this does not affectthe essential nature of Reiki. For these reasons, Reiki and other similar therapeutic techniquescannot be identified

with what Christians call healing by divine grace.

 

9. The difference between what Christians recognize as healing by divine grace and Reiki therapy is also evident in the basic terms used by Reiki proponents to describe what happens in

Reiki therapy, particularly that of “universal life energy.” Neither the Scriptures nor the Christian tradition as a whole speak of the natural world as based on “universal life energy” that is subject to manipulation

by the natural human power of thought and will. In fact, this worldview has its origins in eastern religions and has a certain monist and pantheistic character, in that distinctions among self, world, and God tend

to fall away.[viii]We have already seen that Reiki practitioners are unable to differentiate clearly between divine healing power and power that is at human disposal.

 

III.             CONCLUSION

 

10. Reiki therapy finds no support either in the findings of natural science or in Christian belief. For a Catholic to believe in Reiki therapy presents insoluble problems. In terms of caring

for one’s physical health or the physical health of others, to employ a technique that has no scientific support (or even plausibility) is generally not prudent.

 

11. In terms of caring for one’s spiritual health, there are important dangers. To use Reiki one would have to accept at least in an implicit way central elements of the worldview that

undergirds Reiki theory, elements that belong neither to Christian faith nor to natural science. Without justification either from Christian faith or natural science, however, a Catholic who puts

his or her trust in Reiki would be operating in the realm of superstition, the no-man’s-land that is neither faith nor science.[ix] Superstition corrupts one’s worship of God by turning one’s religious

feeling and practice in a false direction.[x] While sometimes people fall into superstition through ignorance, it is the responsibility of all who teach in the name of the Church to eliminate such

ignorance as much as possible.

 

12. Since Reiki therapy is not compatible with either Christian teaching or scientific evidence, it would be inappropriate for Catholic institutions, such as Catholic health care

facilities and retreat centers, or persons representing the Church, such as Catholic chaplains, to promote or to provide support for Reiki therapy.

 

 

 

Most Rev. William E. Lori (Chairman) Most Rev. John C. Nienstedt

Bishop of Bridgeport Archbishop of St. Paul and Minneapolis

Most Rev. Leonard P. Blair Most Rev. Arthur J. Serratelli

Bishop of Toledo Bishop of Paterson

Most Rev. José H. Gomez Most Rev. Allen H. Vigneron

Archbishop of San Antonio Bishop of Oakland

Most Rev. Robert J. McManus Most Rev. Donald W. Wuerl

Bishop of Worcester Archbishop of Washington


 

 

[i] See Congregation for the Doctrine of the Faith, Instruction on Prayers for Healing (14 September 2000), I, 3: “Obviously, recourse to prayer does not exclude, but rather encourages the use of effective natural means for preserving

and restoring health, as well as leading the Church’s sons and daughters to care for the sick, to assist the in body and spirit, and to seek to cure disease.”

 

[ii] Catechism, no. 1508. 

[iii] Catechism, no. 1508.

[iv] It has also been claimed that he merely rediscovered an ancient Tibetan technique, but evidence for this claim is lacking.  As we shall see below, however, distinctions between self, world, and God tend to collapse in Reiki thought.

Some Reiki teachers explain that one eventually reaches the realization that the self and the “universal life energy”are one, “that we are universal life force and that everything is energy, including ourselves” (Libby Barnett and

Maggie Chambers with Susan Davidson, Reiki Energy Medicine: Bringing Healing Touch into Home, Hospital, and Hospice [Rochester, Vt.: Healing Arts Press, 1996], p. 48; see also p. 102).

 

[vi]  For example, see “Reiki and Christianity” at http://iarp.org/articles/Reiki_and_Christianity.htm and “Christian Reiki” at http://areikihealer.tripod.com/christianreiki.html and the website www.christianreiki.org.

 

[vii]  Reiki Masters offer courses of training with various levels of advancement, services for which the teachers require significant financial remuneration. The pupil has the expectation and the Reiki Master gives the assurance that

one’s investment of time and money will allow one to master a technique that will predictably produce results.

 

[viii]  While this seems implicit in Reiki teaching, some proponents state explicitly that there is ultimately no distinction between and the self and Reiki. “Alignment with your Self and being Reiki is an ongoing process. Willingness to

continuously engage in this process furthers your evolution and can lead to the sustained recognition and ultimate experience that you are universal life force” (The Reiki Healing Connection [Libby Barnett, M.S.W.],

http://reikienergy.com/classes.htm, accessed 2/6/2008 [emphasis in original]). Diane Stein summarizes the meaning of some of the “sacred symbols” used in Reiki attunements as: “The Goddess in me salutes the Goddess in you”;

“Man and God becoming one” (Essential Reiki Teaching Manual: A Companion Guide for Reiki Healers [Berkeley, Cal.: Crossing Press, 2007], pp. 129-31). Anne Charlish and Angela Robertshaw explain that the highest Reiki

attunement “marks a shift from the ego and self to a feeling of oneness with the universal life-force energy” (Secrets of Reiki [New York, N.Y.: DK Publishing, 2001], p. 84).

 

[ix] Some forms of Reiki teach of a need to appeal for the assistance of angelic beings or “Reiki spirit guides.” This introduces the further danger of exposure to malevolent forces or powers.

[x]  See Catechism, no. 2111; St. Thomas Aquinas, Summa theologiae II-II, q. 92, a. 1.

 

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.


Competence and Informed Consent

Could a competent, adult patient make the wrong decision?  This is not an uncommon issue encountered in the hospital setting. First of all, there is a need to clarify what we mean by a wrong decision. Decisions have to be made at certain points in the course of managing a patient’s condition. Quite often the medical staff has at its disposal several possibilities. So the competent patient is presented with the various options and asked to choose which among them he or she would prefer. The common understanding of the phrase “a patient making the wrong decision” is when the option chosen by the patient is not the one the medical personnel would have picked themselves. Taken to the extreme, a competent, adult patient refusing treatment or any medical intervention whatsoever would very well be interpreted as a wrong decision. This brings us to the question posed at the beginning of this essay. First, I will define competence. Second, I will discuss its significance in relation to obtaining an informed consent. And third, I will address the question above.

The simplest definition of competence is “the ability to perform a task.”[1] From this definition it is important to note that an individual’s competence is directly correlated with the specific task at hand. And in the medical setting this usually pertains to a patient’s competence to make decisions regarding his or her treatment. It is necessary to point out that strictly speaking, it is the court system that evaluates competence/incompetence while the health care professionals determine capacity/incapacity for decision-making. However, these two terms end up being used interchangeably since “this distinction breaks down in practice.”[2]

The determination of an adult patient’s competence is essential in the process of obtaining an informed consent because decisions made by patients who have been declared incompetent are considered invalid while those made by competent individuals would be acceptable. The concept of informed consent relates to two important aspects. The first is that it meets the requirement of getting consent from patients prior to any medical procedure be it diagnostic, therapeutic, or research. And secondly and more relevant to this discussion is that an informed consent represents a person’s “autonomous authorization of a medical intervention or of participation in research.”[3] Clearly competence and the bioethical principle of autonomy are linked inseparably. Competence is a necessary requirement for a person to exercise his or her autonomy.

What then are the criteria that need to be met in order for an adult patient to be declared competent?

(1) The patient should be oriented to time, place, and person. It is possible that a patient could be oriented at certain times and disoriented at other times. Thus it is necessary to continuously track the waxing and waning of the patient on the chart since this could be a crucial element if ever something wrong happens and the case ends up in court.

(2) The patient should understand relevant information. Does the patient understand the basics of the procedure that is being suggested? We have to acknowledge the fact that an average patient would be hard pressed to grasp the medical and technical details of the procedure especially when the medical staff tends to use highly scientific terms when talking with the patient. But a general understanding of the procedure should be acceptable.

(3) The risks and benefits of the various options should be clear to the patient.

(4) The consequences of all options – including the refusal of any treatment – should be clearly understood by the patient as well.

(5) The patient should be able to clearly and voluntarily express (verbally or otherwise) his or her preference. Any sign of coercion or involuntariness would be a red flag.

An adult patient’s competence then enables him or her to give a valid informed consent. As an autonomous individual and having been presented with the various options and their respective risks and benefits, the competent patient is then requested to make a choice. It is the obligation of the medical staff to respect the patient’s autonomy by respecting whatever decision he or she makes.

Now we are back to the question: Could a competent, adult patient make a wrong decision? It is a fact that sometimes medical personnel get so frustrated when a patient makes a choice that is not to their liking. Some have resorted to requesting a psychiatric consult. If they truly have some sound basis for doubting the competence of the patient and just want a confirmation from a psychiatrist, then this seems to be acceptable. They should be reminded that they could also ask their colleagues for a second opinion on this matter. However, if the motive behind the psychiatric consult is to find a way to declare the patient incompetent so they could then convince the relatives, or whoever the surrogate decision-maker would be, to choose their preferred option then this action is not only unacceptable but smacks of paternalism. And in so doing, the patient’s autonomy is not being upheld. If the medical personnel could not in good conscience carry out the choice of the patient, they still have another option – that of passing on the care of the patient to another health care professional. A physician can never abandon the patient so he or she is still responsible for the patient’s care until another physician has accepted this transfer or the patient has decided to leave AMA or against medical advice.

Being human means being imperfect. We make mistakes every now and then. So long as an adult patient has been declared competent then she is merely exercising her autonomy every time she makes an informed decision.

[1] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, Sixth edition (New York: Oxford University Press, 2009) 112.

[2] Beauchamp and Childress 111.

[3] Beauchamp and Childress 119.

Hippocratic Oath & Autonomy

John is a healthy 45-year-old executive who has an appointment with his family doctor for a routine check-up. He read in the newspaper about a new expensive X-Ray test to detect heart disease called CT angiography. John was not concerned that the test was extremely expensive because he thought his insurance would cover it. He told his doctor he wanted to have the test done. The doctor refused his request. He explained that there is no clinical evidence that the test is of value to patients, like John, who have no symptoms or risk factors of heart disease. In addition, a CT angiogram would expose him to unnecessary radiation. John accepted his doctor’s argument, but he still wanted the test to put his mind at ease. Don’t physicians have a moral obligation to respect patient preferences? Isn’t that what the Hippocratic Oath is all about?

The 2500-year-old Hippocratic Oath has stood the test of time. It is still the most popular pledge made by medical students at the time of their graduation. In part, it states, “I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them”. The oath obliges the physician, based on his ability and judgment, to benefit the patient. This is the principle of beneficence. The Oath also places on the physician the obligation not to harm the patient (“primum no nocere”). This is the principle of non-maleficence. In this case, the physician exercises the principle of beneficence by refusing to order a test, which, in his judgment, is not needed. In addition, he exercises the principle of non-malfeasance because, in his judgment, the test may be harmful to the patient. It would expose him to unnecessary radiation.

Notice that the Hippocratic Oath is subjective. It is based strictly on the physician’s judgment even if his colleagues do not agree. Also, notice that it is based on the physician’s judgment, not the patient’s. The Oath implies that the physician has the experience and expertise to make decisions on behalf of the patient even if his judgment is in conflict with the patient’s wishes, as it is in this case. Thus, the Hippocratic Oath does not support John’s argument that the physician has a moral obligation to order a CT angiogram.

Serious challenges to the Hippocratic Oath began in the 1970s. First, one may challenge the way benefits to the patient are assessed. If CT angiograms were considered the standard of care for all patients regardless of symptoms or risk factors, the physician would be hard pressed to refuse the patient’s request for the test. The objective judgment of the profession would trump the subjective judgment of one physician. However, that is not the case here. At this time (July 2008) there is no objective evidence to support the benefit of this test in John’s case.

Another challenge to the Hippocratic Oath came for the American Medical Association. Although its previous codes were essentially Hippocratic, the AMA changed its code in a dramatic and significant way in 1980. The new version is the first to speak of patient rights. “The physician shall respect the rights of patients, of colleagues and of other health professionals, and shall safeguard patients’ confidences within the constraints of the law”. The 1980 AMA code breaks with the Hippocratic tradition, which does not mention anyone’s rights. From this time onward, the principle of respect for patient autonomy has been on the ascendency.

“Whether respect for the autonomy of patients should have priority over professional beneficence directed at those patients is a central problem in biomedical ethics” (Beauchamp & Childress, Principles of Biomedical Ethics, 2009). In this case John expresses his autonomy right by requesting that his doctor order the expensive test if only to put his mind at ease. The doctor, in turn, applies the principle of beneficence by denying the request because in his professional judgment the test is not indicated in John’s case. Moreover, he applies the principle of non-maleficence by refusing to subject his patient to the danger of unnecessary radiation. How can this conflict be resolved?

The answer to this conflict lies in the principle of distributive justice. Health care spending in the United States is spiraling out of control. New technologies are a major driving force for this increase. The principle of distributive justice refers to an appropriate, equitable, and fair distribution of health care resources. It is not appropriate for a doctor to order unnecessary tests that subject patients to danger. It is not equitable for one person to receive expensive diagnostic testing, merely for peace of mind, while 50 million uninsured Americans cannot afford the costs of basic health care. In addition, it is not fair to burden society with unnecessary costs.

Daniel Callahan, an expert on bioethics, argues that solving the current crisis in our health care system – rapidly rising costs and dwindling access – requires replacing the current “ethic of individual rights” with an “ethic of the common good”. In a similar vein Newsweek columnist, Robert J. Samuelson wrote: “We face a choice between a society where people accept modest sacrifices for a common good or a more contentious society where groups selfishly protect their own benefits.”

Artificial Hydration and Nutrition

Question: My mother is 92-years-old and has lung cancer that has metastasized to her liver and brain. She has been declared incompetent and terminal by her physicians. She has stopped eating and her physicians have asked the family to consider inserting a feeding tube in her to give her nourishment. Are we required to insert a feeding tube?

Answer:

Traditional moralists made a clear distinction between allowing-to-die, which entails foregoing disproportionate means where death is foreseen but not directly intended and direct killing by euthanasia. Allowing a patient to die by foregoing aggressive, non-beneficial treatments is not only morally permissible, but it is treating the patient with dignity and respect. The decision is based on the fact that physiological existence no longer offers these patients any hope at all of pursuing those goods for which human life is the fundamental condition. I would conclude that if the family believes that the feeding tube is burdensome and does not offer a reasonable hope of benefit for their mother, then the feeding tube would not need to be inserted. One option would be to place their mother in hospice or move toward palliative care only.

This position is supported by the tradition of the Catholic Church. The history of the Catholic Church’s position on the ordinary-extraordinary means distinction dates back to the 16th century Dominican moralists. The Dominican moralists, followed the tradition of the Church that states human life is a good but not an absolute good. As a relative good, one’s duty to preserve it is a limited duty. While a person has freedom over his or her life, one is never permitted to directly take one’s life. The issue becomes to what extent is one obligated to preserve one’s life. The traditional understanding of ordinary-extraordinary means remained basically unchallenged until the mid-1900s with the advent of advances in medicine and technology. How to apply the early distinction of ordinary-extraordinary means to issues like oxygen and feeding tubes, especially with permanently unconscious patients became hotly debated as early as the 1950s. Jesuit moralist Gerald Kelly was one of the first to examine this issue critically. He defined ordinary means of preserving life as “all medicines, treatments, and operations, which offer a reasonable hope of benefit for the patient and which can be obtained and used without excessive expense, pain, or other inconvenience.” Extraordinary means would be “all medicines, treatments, and operations, which cannot be obtained or used without excessive expense, pain, or other inconvenience, or which, if used, would not offer a reasonable hope of benefit” (Kelly, Medico-Moral Problems, 1957). The distinctive element of Kelly’s interpretation is that it is a patient-centered, quality-of-life approach which is consistent with how the 16th-century-Dominican moralists viewed this distinction. Kelly concludes that no person is morally obligated to use any means, and this would include natural or artificial means, that does not offer a reasonable hope of ameliorating the patient’s condition.

A contemporary understanding of the ordinary-extraordinary means distinction was given in the 1980 Congregation for the Doctrine of the Faiths’ Declaration on Euthanasia. The Declaration follows the tradition on the ordinary-extraordinary means distinction since the 16th century, which is based on the effect of the treatment on the patient or those responsible for the care of the patient. The Declaration reminds us of the duty one has to care for one’s own life and to seek such care for others. But there are limits to this obligation. One needs to judge the means used 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” (Congregation for the Doctrine of the Faith, “Declaration on Euthanasia,” 1980). The Declaration goes on to give four examples: patients are permitted to use experimental, advanced medical techniques, which may be a service to humanity; patients may interrupt treatments if they fall short of expectations; the refusal of a technique that is in use and carries a risk or is burdensome is not equivalent to suicide; finally, when death is imminent in spite of the means used, it is permitted in conscience to make 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 (Congregation for the Doctrine of the Faith, 1980). Finally, the Congregation for the Doctrine of the Faith reflects the traditional teaching when it writes: “Life is a gift from God, and on the other hand death is unavoidable; it is necessary, therefore, that we, without in any way hastening the hour of death, should be able to accept it with full responsibility and dignity” (Congregation for the Doctrine of the Faith, 1980). The only real change is that the document realizes that the terms ordinary and extraordinary are imprecise as terms in regards to the rapid advancement of medicine and technology. More precise terms would be proportionate and disproportionate (Congregation for the Doctrine of the Faith, 1980).

The U. S. Conference of Catholic Bishop’s fourth edition of the Ethical and Religious Directives for Catholic Health Care Services (ERDs) provide authoritative ethical guidance for all those working in Catholic Health Care facilities. The introduction to Part 6 states the more restrictive standard: “These statements agree that hydration and nutrition are not morally obligatory either when they bring no comfort to a person who is imminently dying or when they cannot be assimilated by the person’s body” (United States Catholic Conference of Bishops, Introduction-Part 6, 2001). Directive 58 states clearly that, “There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient” (United States Catholic Conference of Bishops, 2001). This directive follows the traditional understanding of the ordinary-extraordinary means distinction, in which the benefits-burdens are understood broadly relative to the patient.