BY: FR. MICHAEL D. PLACE, STD
Fr. Place is president and chief executive officer, Catholic Health Association,
St. Louis.
The topic of Health Progress's special section this issue is one
that is very important to Catholic health care: providing effective and compassionate
palliative care. The reason we are so attentive to this subject is because of
our concern for preserving, protecting, and enhancing the dignity of the human
person. The alleviation of pain and suffering is an expression of our commitment
to eliminate, as fully as possible, obstacles to living that dignity. In some
instances, the provision of palliative care also is associated with our care
for the terminally ill and the dying. In this instance, our commitment to human
dignity is complemented by our belief that this life is a journey to everlasting
life. This larger perspective provides both nuance and motivation to our care.
In the instance of care for the terminally ill and dying, we are guided by
clinical protocols as well as by a rich tradition of ethical reasoning. Obviously,
because such ethical discernment offered is case and fact specific, it requires
prudential reasoning in discovering what is morally required or possible. That
prudential reasoning is guided by a variety of ethical principles, such as the
distinction between ordinary and extraordinary care. Over the years there have
been articles in Health Progress about a variety of moral issues associated
with the utilization of this principle. Among the most complex and, at times,
contentious has been the discussion concerning the parameters of our moral obligations
with regard to the provision of artificial nutrition and hydration to dying
patients, as well as to persons who are diagnosed to be in a persistent vegetative
state. Though the Ethical and Religious Directives provide authoritative
guidance on this topic, discussion and debate has continued about what constitutes
the morally appropriate range of clinical decisions (see below).
That being said, a certain consensus has developed within many parts of Catholic
health care about an ethically appropriate range of care and decision making
with regard to nutrition and hydration.
The Allocution's Context
It was in this context of consensus and debate that a recent allocution by
the Holy Father addressing some aspects of this complex dispute has drawn much
attention. As I write these reflections, the text remains the subject of study.
The current guidance found in the Ethical and Religious Directives remains
normative. In fact, it could be said that many aspects of the allocution are
a reaffirmation of current practice. It also could be that further study of
the text will reveal that the allocution is more of a theoretical clarification,
the application of which will have limited clinical or pastoral significance.
In the meantime, the confusion created by media attention remains quite challenging.
In studying any ecclesial document, it is critically important to understand
the context in which it is written. Papal and other church documents often are
prepared in response to ecclesial, political, or cultural realities. Though
only the Holy Father and those who advise him know what their "front-of-mind"
context was for this text, it is not difficult to surmise some of the realities
that the allocution seeks to address. Allow me to outline those that come to
my mind.
Clinical Advances The practice of medicine, especially in the First
World, continues to advance. Because of human intervention, life often goes
on when previously it would have naturally ended. There are a range of technical
and clinical options that previously did not exist. In this evolving and expanding
situation, there are several dangers. First, a patient could be perceived or
understood merely as a clinical condition, rather than as a human person imbued
with inalienable dignity. Second, advances in options could be evaluated from
a technological or scientific perspective, rather than from the perspective
of the well-being of the human person.
Moral Methodology A consistent concern of the Holy Father has been about
affirming the reality of objective moral order. An attitude of relativism, especially
in the West, is of grave concern, especially if it were to affect Catholic moral
reasoning, and, in particular, if it were to affect the way we in the ministry
evaluate ethical issues pertinent to those who are most vulnerable.
Culture of Life Intimately related to the above is the Holy Father's
unwavering attention to promoting an authentic culture of life as an antidote
to a culture that would evaluate human dignity, not from the perspective of
its God-given worth, but, rather, according to a utilitarian calculus that would
construe human worth on criteria associated with what one can do or achieve
rather than who one is. It is this utilitarian perspective that constitutes
the ethical groundwork for considering the taking the life of the unborn via
abortion, or assisting in the ending of the life of the terminally ill via assisted
suicide, to be morally or ethically acceptable.
Public Order In light of what has already transpired in the United States
and in parts of Europe, and being quite concerned about what will become the
fundamental law of the European Union — especially with regard to protecting
human life from conception to natural death — the Holy Father has been quite
insistent on affirming the need to preserve the common good and the well-being
of society by resisting the movement to legalize the taking of innocent human
life, whether it be by abortion or euthanasia. This conviction is informed,
in part, by the belief that civil law is not just a human convention but is
itself accountable to the objective moral order. Well aware of the violence
done to the human person and the common good that he personally experienced
under Nazism and Communism, he is insistent that civil law not institutionalize
the absence of regard for life.
Continuing the Dialogue
While, as noted earlier, no one can be certain that these realities were explicitly
the context for the recent papal allocution, I believe that they certainly are
part of the context for contemporary papal thinking. It is important that they
be kept in mind as we continue our study and dialogue.
Nutrition and Hydration
"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."
— Directive 58, Ethical and Religious Directives for Catholic Health
Care Services, U.S. Conference of Catholic Bishops, Washington, DC, 2001, p. 31.