I REMEMBER having a conversation with an intensive care doctor who told how when a patient was admitted to intensive care the family would frequently say “we want you to do all that you can for …”
The doctor doubted that they understood what “do all that you can” might mean, and that “doing all that you can” might not be the best care for the patient.
When it comes to “end of life” decision-making there is often a lack of understanding regarding our duty of care.
Sometimes this misunderstanding is exploited in debates about euthanasia and assisted suicide.
In what follows I am not so much concerned with what is euthanasia, but what is not euthanasia.
Some people, including many Catholics, might be surprised to know that we are not obliged to do “all that we can” in order to preserve life – our own, or someone else’s.
Often it is quite appropriate not to do something that might prolong a person’s life.
I begin with a general ethical principle regarding respect for human life.
In the context of health care we can express that principle as follows: “If a person is ill he or she is obliged to seek help to maximise their chances of recovery and to minimise the effects of chronic disability or handicap. If illness is life-threatening a person should seek to avert the threat.”
This duty is founded upon the fact that human life is a basic human good to be respected and cared for.
The negative norm, which I would consider a moral absolute, is: You should not directly attack the good of life – there is no such thing as a life unworthy of life. Euthanasia and assisted suicide obviously disregard this moral norm which has been integral to the mores of our society for centuries.
The positive duty rules out one kind of bad practice, what is referred to as “under-treatment”.
“Under-treatment” can be defined as the failure to take appropriate measures to treat symptoms or the condition itself, when those measures could bring real relief and are not considered too burdensome or intrusive.
The language that is often used here to justify lack of treatment is that of futility.
A treatment is futile when the treatment does not achieve its purpose.
So if the treatment is aimed at cure, when cure is no longer possible, then that is futile treatment.
Sometimes the continuation of chemotherapy, for example, may be futile because of the progression of the cancer.
Artificial nutrition is aimed at giving nutrition.
But if the body processes have already begun to break down such that food is no longer being digested, then artificial nutrition is futile as it is not achieving its purpose.
Also there are limits to our positive duty.
Just as there is no obligation to pursue futile treatment, so there is no obligation, other things being equal, to undergo treatment that imposes excessive hardship or burden. Burdensomeness might be physical, psychological (including cultural and personal sensibilities), moral, or economic.
In the Catholic tradition we have often referred to “ordinary” and “extraordinary” means of treatment.
For the moralists burdensomeness has in fact been the central criterion in determining whether a “means” is ordinary or extraordinary, i.e. whether a treatment is obligatory or optional.
Pope Pius XII in a famous address to an international Congress of Anaesthetists in 1957 (Nov 24) invoked the distinction between ordinary and extraordinary means saying: “normally one is held to use only ordinary means – according to circumstances of persons, places, times and culture – that is to say, means that do not involve any grave burden for oneself or another”.
The Declaration on Euthanasia from the Sacred Congregation for the Doctrine of Faith also recognises that the term “extraordinary” is imprecise.
In giving guidelines it says “one cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome” and “when inevitable death is imminent … it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life …”
So what constitutes burdensomeness?
In judging how burdensome treatment is, we need to consider the degree of risk, cost, and physical and psychological hardship involved relative to (a) this particular patient, his or her overall condition and its potential for improvement, the patient’s resources and sensibilities (e.g. to the burdens of his or her family), and (b) to this particular doctor (or medical team), their time, effort and other obligations.
Throughout history a great variety of things have been considered burdensome enough to constitute extraordinary means such as: leaving one’s home to go to a more healthful climate; the amputation of a limb; other major operations; and very costly treatments. In many situations, “resuscitation” after cardiac arrest might be considered too burdensome for many patients.
We cannot draw up a list and say, “That’s it. Everything that’s on that list will be considered burdensome”.
It is the individual patient (or the competent person speaking on their behalf) who, having been properly informed by the medical staff as to what the treatment involves and what the likely prognosis is, must decide whether it is too burdensome for him or her.
This is also the problem with Advance Health Care Directives following the Queensland model.
They are a blunt instrument making decisions in complex and unforeseen circumstances.
It is much better to appoint an enduring power of attorney, who knows your preferences, to speak on your behalf if you are no longer competent to do so.
The bottom line is – it is not euthanasia to forgo possibly life-prolonging treatment which is overly burdensome.
Such a decision is not an attack upon the good of human life, but an acceptance of the reasonable limits of medicine.
Dr Ray Campbell is a Brisbane ethicist.
