Respecting human dignity at the end of life

My mother was in an emergency room, gasping for breath, and she seemed to be dying.
Mom was 85 years old, with serious heart and lung problems. My wife and I had rushed her to the hospital when she started being unable to catch her breath. The diagnosis: She had too much fluid around her lungs to breathe properly. Now she was panicking from that crisis and from the claustrophobic experience of having an oxygen mask cover most of her face.
 
As she couldn’t listen or communicate, a doctor said my wife and I had to make a decision. If a diuretic administered to drain off the excess fluid did not work soon, they could step up the medication to relieve Mom’s panic, but then she may not take in enough oxygen. Or they could perform minor surgery to intubate her, which would get her enough air but might raise new dilemmas later if she became dependent on it.
After hemming and hawing and looking at each other in alarm, we were about to approve intubation when a nurse said, “Doctor, I think the diuretic has begun to work.”
 
Mom was breathing more normally, and the crisis passed. She was able to return home with us and live there for more than a year, enjoying her grandchildren and great-granddaughter. Later, she passed away peacefully in hospice care, a few weeks after a final heart attack.
 
This is not an unusual story. Every day, Catholics and others face unexpected dilemmas about treatment for themselves and their loved ones. Each situation is a unique and bewildering set of facts, forcing us to choose what we hope will be the best or “least bad” outcome.
 
So where do we turn for guidance? How does the Church help us make decisions that are consistent with God’s will for us?

Moral principles
People are often surprised to find that Catholic teaching provides no single authoritative answer to many of the questions that arise near the end of life. For example, it has no list of medical treatments we must always use. It does provide key moral principles we can apply to concrete situations, using the virtue of prudence. And those principles are based on a vision of the human person that is at the core of the Gospel.
 
Let’s begin with the principles. They explain two things we must never do, and provide guidance to help us decide what we can and should do for those we love.
 
First is God’s commandment, “Thou shalt not kill.” We must never deliberately take a human life, our own or anyone else’s. Such a wrongful intention might be carried out by a positive act or by omitting needed support in order to bring on someone’s death.
 
Even motives of compassion or altruism cannot justify such taking of innocent human life. In short, we should always reject euthanasia, which is “an action or omission which of itself and by intention causes death, with the purpose of eliminating all suffering” (Pope John Paul II, Evangelium Vitae).
 
Sometimes, the effort to control pain or provide other important benefits to a patient may risk an earlier death as an inevitable side effect; that is not the same thing as deliberately aiming to end the patient’s life, which is always wrong.
 
Second, we must not discriminate against those most in need. We should not lavish every life-saving option on those who are rich or smart or able-bodied or powerful, while ignoring the value of life for people with lesser abilities or accomplishments.
This has enormous implications for our treatment of people with mental or physical disabilities, including those seen as being in a “vegetative state.” Sometimes, demeaning judgments about people with a low “quality of life” have even led to the taking of life, as when some doctors have withheld routine surgery and nourishment from newborn infants with Down syndrome to ensure their death.
 
Third, we have a positive obligation to take reasonable care of our own lives and the lives of those who depend on us. The limits of that obligation are outlined in the distinction between “ordinary” and “extraordinary” means. Some prefer to speak of “proportionate” and “disproportionate” means instead. But the basic idea is that we are not obliged to support and sustain earthly life by every means technically possible. In each case we should ask: Will this treatment have real benefit for this patient, in this particular situation? Can it be effective in sustaining life, alleviating disease or relieving suffering?
 
And even if it can, does it impose serious burdens on this patient – suffering, hardship, expense, etc. – that outweigh those benefits? In other words, we have to assess what good the treatment can do for the patient and weigh it against the harm it may do to the patient.
 
This is where the Catholic virtue of prudence comes in. Prudence is not a reserved or modest attitude. It is the ability to apply general moral principles to a specific situation so we can decide the best action to take here and now. The church has no list of “ordinary” means that must always be used, no matter what, because that judgment will depend on the patient and the details of the situation.
 
The classic case – not the only case – in which life-sustaining treatments can become extraordinary or disproportionate is one in which the person is very near death from a terminal illness, and nothing more can reasonably be done to sustain his or her life: “When death is clearly imminent and inevitable, one can in conscience ‘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’” (Evangelium Vitae, no. 65).
 
In forgoing such overly aggressive treatment, we are not aiming at death but accepting the human condition and the limits of our ability to stave off death.

The fourth principle is about the term used above, “the normal care due to the sick person.” There is a basic level of care we owe to everyone, out of respect for their human dignity. Keeping the patient comfortable, relieving pain, providing personal hygiene – these are things we do for our children when they are very young, and we do them for ailing adults when they can no longer do them for themselves.
 
Providing food and water is part of this basic care, though providing it may require some medical assistance such as tube feeding. Rarely, especially in the final stages of terminal illness, even food and fluids may no longer be effective in providing nourishment or preventing suffering. But as a general rule, they are “a natural means of preserving life, not a medical act,” and we are morally obliged to provide them (Pope John Paul II, Address, March 20, 2004).
 
Fifth, in the context of these moral principles, we should address patients’ pain and suffering. One reason suffering exists in this world is “in order to unleash love in the human person, that unselfish gift of one’s “I” on behalf of other people, especially those who suffer” (Pope John Paul II, Salvifici Doloris,no. 29).
 
We are called to empathize with those who suffer, to keep company with them and alleviate their pain. As Christians, we may also choose to endure suffering and join more closely with Christ by uniting our sufferings with his own; but “such ‘heroic’ behavior cannot be considered the duty of everyone” (Evangelium Vitae, no. 65).
 
Where do these principles come from? What is their basis in a Catholic vision of human life?

The dignity of the human person
The foundation for everything the church says on these and many other moral issues is the dignity of the human person. Each of us, of whatever age or condition, is a unique and unrepeatable gift of God, “a masterpiece of God’s creation,” as Pope Francis has said.
 
The human person is made in God’s image, “the only creature on earth that God has willed for its own sake” (Catechism of the Catholic Church). Each of us was specially created by God out of his boundless love and called to live in ways that make us ready for eternal life with him.
 
Two aspects of this dignity are especially relevant to moral issues near the end of life. First, this incomparable dignity does not belong only to our immortal souls. We are not souls trapped in earthly bodies, “freed” from this prison by death as some philosophers have imagined. We are a union of body and soul, and our bodies share in our human dignity.
 
Death is not a liberation but the separation of a body and soul that belong together. “God did not make death, and he does not delight in the death of the living” (CCC, no. 413, citing Wis 1:13). The cure for our fear of death is not to see death itself as a good thing but to remember that, beyond the suffering of death, there is something infinitely greater – the resurrection of the body and eternity with Christ. Whether we treat bodily life here and now with care and respect will help determine whether we share in that glorious resurrection.

Inherent worth
Second, dignity means inherent worth, beyond all differences of age, illness or disability. Some people speak of “death with dignity” in an immoral sense, glorifying death as a solution to problems. More responsibly, others mean only that people near the end of life need to be treated with respect for the human dignity they still have.
 
In reality, we have that dignity from the very beginning of our lives to its end, and no illness or limitation can take it away. People can remember that and treat us accordingly, or they might forget it and mistreat us as though we have lost our dignity because we lack some physical or mental abilities.
 
“Even our brothers and sisters who find themselves in the clinical condition of a ‘vegetative state’ retain their human dignity in all its fullness. The loving gaze of God the Father continues to fall upon them, acknowledging them as his sons and daughters, especially in need of help” (Pope John Paul II, Address, March 20, 2004).
 
Recognizing the dignity of each person does not paralyze us in the face of illness and death. It frees us to make sensible decisions that respect the gift of life. We must never deliberately attack human life. More than this, we should practice careful stewardship over this gift, taking reasonable steps to support life, improve health and ease suffering. We do not ignore the fearful power of death, but we see it in the perspective of Christ’s ultimate victory over death and his invitation to enjoy eternal life with him.
 
Richard Doerflinger is former associate director of the Secretariat of Pro-Life Activities for the United States Conference of Catholic Bishops.

Richard P. Doerflinger, associate director of the U.S. bishops’ Office of Pro-Life Activities, is one of six winners of the inaugural Life Prizes awarded by the Gerard Health Foundation to “individuals or groups that have made unsurpassed strides in preserving and upholding the sanctity of human life.” He is pictured in Washington in early August. (CNS photo/Nancy Wiechec) (Nov. 26, 2008), 2008) See AWARDS-LIFE to come.