Editor’s Note: An earlier version of this article appeared in the Bioethics Brief of the Alliance of Catholic Health Care.

CANONICAL SIGNIFICANCE OF A LETTER
Circular letters from a curial office are first and foremost pastoral in nature and typically do not break new ground or new teaching. Rather, such letters aim to clarify current teaching or proclaim and organize that teaching in a more comprehensive fashion. Thus, the “weight” or “canonical authority” of anything in it relates more toward the weight that matter had in other teaching documents. Therefore, the footnotes are significant in identifying the foundation of any particular statement. A letter is not new legislation. Nor is it an “instruction,” which specifies the implementation of legislative texts. Nonetheless, such letters are meant to communicate the current state of teaching so as to guide both the thinking of the faithful and the Church’s pastoral practice.

Samaritanus bonus was approved by Pope Francis, indicating he understands the letter as reflecting Church teaching and is pleased to have it issued. His approval does not change the nature of the document and does not make it a papal statement.

PASTORAL TEACHING
Samaritanus bonus emphasizes the responsibility of all who come into contact with critically or terminally ill persons to accompany them with prayerful, compassionate fidelity. Specifically named are relatives or legal guardians, hospital chaplains, extraordinary ministers of the Eucharist and pastoral workers, hospital volunteers and healthcare personnel. Showing care reveals the original and unconditional love of God, the source of the meaning of all life. The letter beautifully recapitulates a theology/ spirituality of suffering with Christ to discover hope that strengthens and endures. The Good Samaritan combines a compassionate heart with practical services of caring. The letter reminds healthcare personnel of their fundamental moral choice: “In intensive care units or centers for chronic illness care, one can be present merely as a functionary, or as someone who ‘remains’ with the sick.”

The letter clarifies that pastoral accompaniment of persons who request euthanasia or assisted suicide must always continue, even when the sacraments cannot be administered. “It is necessary to remain close to [this] person … for this nearness is an invitation to conversion, especially when euthanasia, requested or accepted, will not take place immediately or imminently.” The pastoral imperative is to remain close while avoiding “any gesture, such as remaining until the euthanasia is performed, that could be interpreted as approval of this action.”

PALLIATIVE CARE
Palliative care, hospice and the role of patients’ families are strongly endorsed. The letter cites the Catechism of the Catholic Church (#2279) that “Palliative care is a special form of selfless love. As such it should be encouraged.” Unfortunately, the letter tends to restrict palliative care to terminal illness rather than the more accurate understanding of holistic care to persons with serious health-related suffering due to severe illness. It notes that employment of palliative care reduces considerably the number of persons who request euthanasia. And although it does not provide specifics, the letter warns against national laws on palliative care that incorporate requests for euthanasia and assisted suicide.

MORAL TEACHING
Samaritanus bonus relies heavily for its moral principles on three sources: the CDF’s 1980 Declaration on Euthanasia (Jura et bona), 12 citations; St. Pope John Paul II’s 1995 encyclical Evangelium vitae, 18 citations; and the Pontifical Council for Pastoral Assistance to Health Care Worker’s 2017 New Charter for Health Care Workers, 9 citations. The 99 footnotes also include numerous other magisterial statements from Popes Francis, Benedict XVI, John Paul II, the Catechism of the Catholic Church and previous CDF documents. The letter forcefully highlights the cultural factors driving the increased legalization of euthanasia and assisted suicide, spoken of by Pope Francis as a “throw-away culture” and by Pope John Paul II as a “culture of death.” The letter reiterates the Church’s prohibition of euthanasia and assisted suicide as acts that directly cause the death of an innocent human being. The letter also reiterates the obligation to exclude aggressive medical treatment and the principles that apply to decisions to forgo disproportionate medical treatments. However, in some places, the letter’s interpretation of these principles and the ways they apply to persons who are critically or terminally ill may cause serious confusion and misunderstanding of traditional Catholic teaching.

POTENTIAL FOR MISUNDERSTANDINGS
In various places, the letter suggests that Catholic teaching allows only persons with an incurable terminal illness to justifiably forgo life-prolonging medical treatment. This position is not in accord with traditional Catholic teaching; in fact, it asserts a vitalism contrary to Catholic principles. One clear example of this potential misunderstanding is found in section V, #2, in the sentences, “The suspension of futile treatments must not involve the withdrawal of therapeutic care. This clarification is now indispensable in light of numerous court cases in recent years that have led to the withdrawal of care from — and to the early death of — critically but not terminally ill patients, for whom it was decided to suspend life-sustaining care which would not improve the quality of life.”

• Catholic teaching on ethically acceptable decisions to withhold or withdraw life-prolonging treatment has never been limited to “futile” treatments, whatever that might mean. The key Catholic principle refers to burdensome treatment or non-beneficial treatment as evaluated by each patient. Since limiting acceptable Catholic decisions to only futile treatment would be a momentous change in the tradition, there is need to prevent this misunderstanding.
• Catholic teaching on ethically acceptable decisions to forgo life-prolonging treatment has never been limited to persons with a terminal illness. For instance, it is acceptable for a person to forgo dialysis treatment for chronic kidney disease because of the burdens associated with the treatment — even though it would work to circumvent renal failure by cleansing the blood (this is also true for a person with COPD forgoing a ventilator who could, nevertheless, live for years while ventilator dependent). The distinction between critically ill and terminally ill persons in this paragraph creates confusion about the very foundation of Catholic teaching, i.e., the inherent dignity of the person integrally considered. There is need to prevent this misunderstanding.

While acknowledging these potentials for confusion, this letter does not appear to make any significant change in the customary understanding of Catholic principles about decisions to use or to forgo life-prolonging medical treatment. Nor does the letter change the usual application of these principles to evaluate the burdens and benefits of medical treatment for persons who are both critically and terminally ill. In fact, any such radical departure from traditional teaching would not be compatible with the typical purpose of a letter. Nevertheless, some commentators may be quick to interpret certain statements in the letter in a vitalist manner that would distort the tradition.

WARNINGS TO HEED
The letter warns about the dangers that can arise when Do Not Resuscitate Orders or POLST documents are misused or abused. The letter emphasizes that it is crucial to provide the patient or family participants with free and informed consent. Similarly, the consciences of health professionals must be safeguarded. The advocacy and educational efforts of CHA and Catholic health systems nationwide provide outstanding examples of defending against these dangers.

The letter’s treatment of artificial hydration and nutrition, for adults and children, is nearly identical to the teaching of the Ethical and Religious Directives for Catholic Health Care Services, #58. Even though the ministry’s excellent educational efforts on this potentially confusing topic have advanced accurate understanding of Church teaching, additional effort is necessary to clarify ethically acceptable options to forgo medically assisted nutrition and hydration. Far too many persons in parishes as well as in health care facilities erroneously believe the Church teaches that artificial hydration and nutrition must always be used in all cases.

JOHNNY COX, RN, PH.D.
Ethicist
Surprise, Ariz.
[email protected]