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BY: RON HAMEL, Ph.D.

Palliative care and hospice are under attack. They are being accused by some of being nothing more than "stealth euthanasia." The accusation is not new; it has appeared in blogs and some conservative Catholic newspaper stories over the years. The attacks, however, seem to be gaining more visibility and, possibly, more influence by appearing in some relatively well-known Catholic publications.

While these attacks unfortunately have planted seeds of doubt about the integrity of palliative care and hospice, they also may have sounded an alarm on possible abuses, in some instances, of end-of-life care. If such abuses do exist, they need to be addressed lest they gain legitimacy and frequency and mar the immense good that palliative care and hospice do in the care of chronically and terminally ill patients and their families.

One of the first challenges to palliative care and hospice to appear in a Catholic journal was a 2006 article by Romanus Cessario, OP, "Catholic Considerations on Palliative Care."¹ Cessario raised doubts about the moral acceptability of palliative care and hospice. Commenting on the National Hospice and Palliative Care Organization's mission statement, Cessario stated:

The test of a palliative care lies, so the organization asserts, in the agreement between the individual, physician(s), primary caregiver, and hospice team that the expected outcome is relief from distressing symptoms, the easing of pain, and the enhancement of quality of life. The moral theologian will observe with caution, if not alarm, the amenability of this description to be put at the service of moral expediency. …

We should take account of the fact that principles, values, suppositions, and objectives that govern the administration of palliative care remain sufficiently broad and formal to require Catholics to pay them serious attention. While the WHO [World Health Organization] definition of palliative care contains no provision that contravenes the Catechism of the Catholic Church, n. 2279, one should not assume that the implementation of these provisions will remain 'unambiguously pro-life'….

As it now stands, the NHPCO mission statement leaves itself open to allowing palliative care that would contravene the moral law, especially inasmuch as terms like 'quality of life,' 'values,' and 'decisions' invite judgments ordered toward assisted suicide or euthanasia.²

Although Cessario acknowledges that palliative care and hospice do good, he also has called them into question and insinuated that their purposes and practices might not be consistent with Catholic moral teaching.

More recently, Ethics & Medics published an article titled, "The Rise of Stealth Euthanasia." Here the authors claimed that "many hospice and palliative care physicians are urging, and actually performing, euthanasia by stealth. They administer sedatives that in themselves do not cause immediate death, but knowingly cause the conditions that result in death. This misuse of terminal sedation with intent to end life is properly termed 'stealth euthanasia' — it is not active euthanasia or passive euthanasia, but a combination of both."³

Stealth euthanasia is occurring, the authors contended, because physicians in palliative and end-of-life care settings are increasingly intending to kill patients through the administration of opioids and palliative sedation, while appealing to the principle of double effect. "It is horrifying that health care professionals … intentionally hasten death while pretending to be providing appropriate end-of-life care. That this is a pretense is becoming more and more evident to patients and families."

Furthermore, the authors claim that patients who are not terminal are being admitted to hospice, some chronically ill with conditions such as Alzheimer's and brain damage, only to die from dehydration. They maintain that withholding nutrition and hydration is "often done with the intention that the patient die" and that "physicians who seek to continue providing food and fluids are often pressured not to do so." Indeed, they state, "the culture of death has deeply infiltrated the hospice and palliative care industry."

What evidence is proffered to support these charges? The evidence is anecdotal. "A nurse informed one of the authors …" and "many in the field of hospice and palliative care … as well as physicians across the country, confirm that there is a clear trend toward hastening deaths of patients." In addition, "internationally known hospice and palliative care leaders confirm these reports," and "traumatized families are reporting the hastened deaths of loved ones, and hospice and palliative care providers are warning that euthanasia and stealth euthanasia are sometimes being performed in end-of-life care settings."

The latest challenge to palliative care and hospice appeared in the November 2013 issue of Ethics & Medics, an article titled "A Planned Death for My Father."⁴ The anonymous author recounted the story of his/her father, who was receiving hospice care in an assisted living facility, and was deliberately deprived of nutrition and hydration, leading to his death. At one point in the account, the author wrote: "As the employees of father's assisted living facility came by on their regular rounds, I told them that my father was being killed. They acknowledged that I was right. They were very aware of what was happening."

The author concluded by saying that he/she was recounting the story "in the hope that others will help reverse this frightening trend toward euthanizing our most vulnerable populations."

What are we to make of the claims in these articles? First, it is quite possible, if not likely, that what is described does occur. Some physicians probably do employ opioids or palliative sedation, or the withdrawal of nutrition and hydration, to bring about the death of some of their patients. However, it is far from clear whether these are isolated incidents or relatively frequent practices. It is irresponsible in so many ways to infer the latter without solid evidence, and that would be very difficult to come by. It is also irresponsible to generalize from one or several instances to postulate a widespread problem. The fact that there may be some abuse by some physicians does not vitiate all of palliative care and hospice. Nor does it mean that all of palliative care and hospice have been infiltrated by a culture of death.

Second, these practices can occur outside the context of palliative care and hospice. Not all patients who receive opioids or who opt for palliative sedation are, in fact, receiving palliative or hospice care. Hence, to associate and limit the abuse of these practices, assuming they do occur, with hospice and palliative care is misleading at best. But more seriously, it is extremely harmful to all the efforts that have been and are being made to have palliative care programs in place in acute and long-term care facilities.

Immense progress has been made over the years, but there is still a long way to go. The charges by these authors, the seeds of doubt they have planted, can not only undermine further progress in advancing palliative care and hospice, but also undermine the confidence of patients, families and physicians in the benefits of palliative care and a willingness to make use of it. While attempting to call attention to abuses in end-of-life care, the authors have dealt a blow to the best hope for improved end-of-life care that currently exists. In trying to save the lives of some dying patients, they have contributed to undermining good care for tens of thousands of other dying persons.

Third, let us not forget that two recent popes — John Paul II and Benedict XVI —have explicitly endorsed palliative care. John Paul II mentioned palliative care in his encyclical Evangelium Vitae, in the context of his discussion of decisions to forgo disproportionate medical treatments.⁵ Many years later, he was more explicit in his support:

Particularly in the stages of illness when proportionate and effective treatment is no longer possible, while it is necessary to avoid every kind of persistent or aggressive treatment, methods of "palliative care" are required. As the encyclical Evangelium Vitae affirms, they must "seek to make suffering more bearable in the final stages of illness and to ensure that the patient is supported and accompanied in his or her ordeal" (n. 65).

In fact, palliative care aims, especially in the case of patients with terminal diseases, at alleviating a vast gamut of symptoms of physical, psychological and mental suffering; hence, it requires the intervention of a team of specialists with medical, psychological and religious qualifications who will work together to support the patient in critical stages.⁶

This statement, as the one from Evangelium Vitae, is followed by a brief discussion of the licit use of pain killers and the need to avoid the administration of "massive doses of a sedative for the purpose of causing death."

Pope Benedict XVI endorsed palliative care on several occasions. In his message for the 15th World Day of the Sick, for example, Benedict stated:

There is a need to promote policies which create conditions where human beings can bear even incurable illnesses and death in a dignified manner. Here it is necessary to stress once again the need for more palliative care centers which provide integral care, offering the sick the human assistance and spiritual accompaniment they need. This is a right belonging to every human being, one which we must all be committed to defend.⁷ [emphasis added]

In 2009, while visiting the Hospice Foundation of Rome, Pope Benedict again referred to palliative care:

Whoever has a sense of human dignity knows instead that they must be respected and supported while they face the difficulties and sufferings linked with their health conditions. Toward this end, today one takes recourse more and more to the use of palliative care, which is able to soothe pain that comes from the illness and to help infirm persons to get through it with dignity. Nevertheless, together with the indispensable palliative care clinics, it is necessary to offer concrete gestures of love, of nearness and Christian solidarity to the sick…."⁸

Fourth, in light of these accusations, Catholic health care, especially palliative care and hospice programs in Catholic health care facilities, needs to be vigilant against abusive practices that counter a Catholic approach to end-of-life care. Such practices undermine a Catholic understanding of palliative care and hospice and could end up undermining the immense progress that has been made to date in supporting and assisting those with chronic and terminal illnesses. Toward this end, Catholic health care organizations should be clear about the Catholic tradition regarding the use of opioids, a proper understanding of what is and is not a morally licit use of palliative sedation and when it is morally permissible to withhold or withdraw medically administered nutrition and hydration.

Vigilance also is necessary when partnering with or joining coalitions and organizations devoted to promoting good end-of-life care. It is no secret that Compassion & Choices (formerly the Hemlock Society), a national nonprofit group that works to "protect and expand options at the end of life,"⁹ has attempted and continues to attempt to infiltrate some of these groups.

There is too much at stake here for Catholic health care not to be vigilant and not to take pre-emptive measures. As the Ethical and Religious Directives for Catholic Health Care Services so eloquently and aptly state: "What is hardest to face is the process of dying itself, especially the dependency, the helplessness, and the pain that so often accompany terminal illness. One of the primary purposes of medicine in caring for the dying is the relief of pain and the suffering caused by it. Effective management of pain in all its forms is critical in the appropriate care of the dying. … The task of medicine is to care even when it cannot cure."¹⁰

Palliative care and hospice are the best hope for achieving these goals.

RON HAMEL, Ph.D., is senior ethicist, Catholic Health Association, St. Louis.

NOTES

1. Romanus Cessario, "Catholic Considerations on Palliative Care," National Catholic Bioethics Quarterly 6, no. 4 (Winter 2006): 639-650.
2. Cessario, 642, 643-44, 645.
3. Ralph A. Capone et al., "The Rise of Stealth Euthanasia," Ethics & Medics 38, no. 6 (June 2013): 2-4.
4. Anonymous, "A Planned Death for My Father," Ethics & Medics 38, no. 11 (November 2013): 3-4.
5. John Paul II, Evangelium Vitae, (March 25, 1995), par. 65, www.vatican.va/holy_father/john_paul_ii/encyclicals/documents/hf_jp-ii_enc_25031995_evangelium-vitae_en.html.
6. John Paul II, "Address to the Participants in the 19th International Conference of the Pontifical Council for Health Pastoral Care," (Nov. 12, 2004): par. 5, www.vatican.va/holy_father/john_paul_ii/speeches/2004/november/documents/hf_jp-ii_spe_20041112_pc-hlthwork_en.html.
7. Benedict XVI, "Message of His Holiness Benedict XVI for the 14th World Day of the Sick," (Dec. 8, 2005), www.vatican.va/holy_father/benedict_xvi/messages/sick/documents/hf_ben-xvi_mes_20051208_world-day-of-the-sick-2006_en.html.
8. Benedict XVI, "Address of His Holiness Benedict XVI on the Occasion of His Visit to the Hospice
   Foundation of Rome," (Dec. 13, 2009), www.vatican.va/holy_father/benedict_xvi/speeches/2009/
   december/documents/hf_ben-xvi_spe_20091213_hospice_en.html.
9. Compassion & Choices website, "Who We Are," www.compassionandchoices.org/who-we-are/about/.
10. United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, 5th edition, (Washington, DC: USCCB, 2009), Part Five, Issues in Care for the Seriously Ill and Dying, Introduction.