REVIEWED BY MARY JO LOZZIO, PhD
Medical Care at the End of Life: A Catholic Perspective
By David F. Kelly
Georgetown University Press
Washington, DC, 2006
192 pp., $16.95 (paperback)
David Kelly, a veteran ethicist in the classroom and hospital, has developed a no-nonsense, jargon-free, accessible text on end-of-life health care decision making for a wide range of publics and especially for the faithful confident in the Catholic Church and U.S. law. Fluent in both the Catholic medical/bioethical tradition and precedent-setting case law in the United States, Kelly navigates the developmental history of an American consensus in matters of end-of-life treatment decisions.
He identifies three pillars of consensus that surfaced with 1) emergent medical technologies; 2) the public's exposure to the plight of patients and families, physicians, health care teams, and hospitals; and 3) a legal system caught off guard and forced to respond without court proceedings.
These pillars of consensus will be familiar to readers of Health Progress, although their mutual influence may have gone unnoticed. Kelly traces this influence through his consideration of the distinctions — the first and second pillars of consensus — between "ordinary" and "extraordinary" means and between killing, on one hand, and "allowing to die," on the other. The third pillar extends the rights and laws protecting personal autonomy, privacy, and liberty to health care decision making regarding the distinctions of ends and means.
Kelly reminds us that much of what has become U.S. law and standard medical decision-making policy in matters of end-of-life care was derived from Catholic sources — both individuals (e.g., Fr. Gerald Kelly, SJ; Fr. Richard McCormick, SJ; Fr. Kevin O'Rourke, OP, and others) and the magisterium. He explains the origins and development of Catholic thinking on the critical distinctions between ends and means by reference to the precedent-setting cases of Karen Quinlan (1976), Claire Conroy (1985), Paul Brophy (1986), Nancy Cruzan (1990), Helga Wanglie (1991), and Terri Schiavo (2003, 2005) and by his own experience with patients and their families, ethics committees, students, friends, and family members. The reasoning behind these experiences all point to the first and second pillars and lead directly to the Patient Self-Determination Act of 1990, and laws concerning advance directives, withholding and withdrawing treatment, and palliative care.
While some have suggested that the ordinary/extraordinary means distinction is unhelpful, Kelly argues for its continued use on the practical grounds that regular people understand it. That the distinction requires nuance permits opportunities for patients, family members, and the health care team to understand the relative value of treatment options and to be confident that an informed decision has been made. Likewise, the distinction between killing and allowing to die, while often misunderstood in the media and by the public, remains crucial in order to avoid the slippery slope toward active euthanasia (and its first cousin, physician-assisted suicide) as well as to assure family members that higher dosage administration of analgesics or the removal of particular technologies is permissible and may be morally obligatory despite the likelihood that such actions may hasten death. These two distinctions remain the principal features of the most protracted of recent cases, that of Schiavo, a young woman who suffered traumatic brain injury resulting in a permanent vegetative state (see Fr. Kevin D. O'Rourke, OP, JCD, STM, "Artificial Nutrition and Hydration and the Catholic Tradition," p. 50).
The Schiavo case actually represents the integration of the three pillars. The medical community argued over the ordinary/extraordinary distinction of continued administration of nutrition and hydration. The media and interested third parties argued over the killing/allowing to die distinction through starvation or pathological causes. And the courts argued over who could lawfully decide on Terri's behalf. Kelly concludes that medically provided nutrition and hydration were extraordinary, that both withdrawing and withholding them were morally acceptable, and that her husband was the appropriate surrogate decision-maker in Terri's case.
This book provides an exploration of the critical thinking necessary for a wide audience to make fully informed decisions regarding end-of-life health care treatment decisions. It is sufficiently detailed through narratives and the application of cases to the author's own experience. Ethics committees, medical practitioners, patients and their families, and college bioethics classes will find the text useful for continuing education, clarification, and discussion.
Mary Jo Iozzio, Ph.D.
Associate Professor, Moral Theology,
Department of Theology and Philosophy,
Barry University, Miami Shores, FL