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Hospice Care and Catholic Ethics
Is Hospice care consistent with Catholic bioethics? Chapple, in her discussion of the topic "Hospice care" in Catholic health care ethics, argues that ultimately the answer is yes, but she acknowledges that there are levels of difficulty in answering the question (Chapple 2009). The ethics of Hospice care present us with a complicated question, insofar as Catholic teachings on end-of-life care have at times provoked public controversy -- the most noteworthy example within recent memory was the Congressional and Presidential intervention in Terri Schiavo case, which brought Catholic teachings about medical intervention at the end of life into national debate and discussion. The Schiavo case was about a straightforward case of euthanasia, and to a certain degree Catholic teachings about hospice care resemble (in their logic about the nature and purpose of human life and death) the Catholic teachings about larger end-of-life issues. The ultimate lesson may be that Hospice care is consistent with Catholic ethical teaching provided it does not stray into areas which are clearly forbidden under that teaching, such as assisted suicide or euthanasia. In terms of ethical teaching, the Fifth Commandment is not easily or persuasively defined away.
For a start we must define precisely what Hospice care entails. Hospice is only an option for those who are terminally ill, and who are no longer determined to pursue active treatment of the illness. To some extent, then, Hospice may sound like a form of assisted suicide -- what the patient will be dying from is the terminal illness itself, untreated. For this reason we must ask whether Hospice in some way represents a withholding of certain necessary medical treatments, and if it is in any way a sin it must be one of omission rather than commission, not what a person does so much as what a person fails to do. To a certain degree, then, we may recall the problems of the Terri Schiavo case, which popularized the notion that Catholic teaching required keeping end-of-life patients alive by any means necessary: of course Schiavo would not have been a candidate for hospice care, as she was in a persistent vegetative state for a number of years, and doctors were not inclined to think a miraculous cure for Schiavo would be likely. But Schiavo was kept alive with relative ease, by means of a feeding tube -- and it is true that the Catholic church insists upon an ethical obligation to provide a bare minimum of care, to the level of a hospital bed and a feeding tube. It is worth noting that the Catechism of the Catholic Church actually distinguishes here between "ordinary means" of keeping another person alive (food, water, medical care) and the "extraordinary." To withhold the "extraordinary" is not necessarily a violation of church teachings, according to the Catechism itself:
2278. Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of "over-zealous" treatment. Here one does not will to cause death; one's inability to impede it is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected. (Catechism, n.p.)
The distinction between Hospice care and straightforward euthanasia is thus captured in a phrase: in Hospice care "one does not will to cause death" but obviously the removal of the feeding tube from Terri Schiavo was intended for no other purpose than to cause death. But this becomes, then, the ethical sticking-point for questions of Hospice care within specifically Catholic teaching. It is worth noting that the Catechism goes on to note that "palliative care is a special form of disinterested charity. As such it should be encouraged." (Catechism 2279). If Hospice care consists of nothing but palliative care, then, it should be seen as not merely permissible but praiseworthy, according to the Church itself.
To a certain degree, then, we can argue that Catholic teaching on Hospice is automatically defined by means of what sort of patients would be considered eligible for Hospice care ethically under Catholic standards. Terri Schiavo's feeding tube was, of course, not particularly burdensome or dangerous or extraordinary, and it served its function of preventing Terri Schiavo from starving to death. The Catholic standards of care therefore insisted upon the maintenance of Schiavo's feeding tube as ethically necessary for end of life standards of care -- the patient is being fed. But what if the only care available to stop the progress of a disease was dangerous, or experimental -- or what if no adequate care actually exists? This is a situation quite common with different types of cancer, for example: there are not many effective medications to combat stage four adenocarcinoma of the lung, and a cancer as far advanced as stage four is basically going to require such high dosage of chemotherapy to combat in any meaningful way that the cure may very well kill the patient sooner than the disease. This is what the Catechism has in mind when it absolves the patient from any ethical necessity to pursue "extraordinary means" to stay alive. But as Chapple notes, and other proponents of Hospice care have argued, Hospice is not the withholding or abandoning of medical care, because it is closer to a redirection of the goal of medical care for that patient. Just because Hospice no longer has as its goal curing the illness does not mean that Hospice stops offering care to the patient -- instead, the care has become palliative, intended to improve the quality of life for the patient, with goals like reduction of pain and retention of mobility.
Yet we have not entirely finished with the concept of Hospice care as a kind of means of procuring death on the part of the patient. Obviously Catholic ethics are no more permissive toward suicide than they are toward relieving us of our moral obligation to provide our fellows with the basic minimum required to sustain life and health -- although a certain amount of ambiguity is acknowledged by the Catechism as unavoidable in its discussion of the good intentions (which may nevertheless pave a road to hell) on the part of those who assist another in suicide "in order to eliminate suffering." And to a certain degree, this also lingers on in a popular notion of Hospice care as entailing painkillers in gradually increasing dosage, perhaps even pushed to the level of overdose -- this is, of course, a myth, but one which is remarkably persistent even among medical people. It is worth noting, however, that this is based on a fundamental misconception about the nature and purpose of Hospice care. The counterintuitive-sounding truth was expressed with remarkable candor by Dr. Atul Gawande, American physician and medical correspondent for the New Yorker magazine. Gawande confesses that, even as a doctor, he had little idea of what results hospice care actually offered:
Like many people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain. But studies suggest otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure. They found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer. Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months. The lesson seems almost Zen: you live longer only when you stop trying to live longer. (Gawande 2010)
The paradox of this is remarkably consistent with the Catholic Church's teaching that palliative care is governed by a special sort of grace that covers unusual acts of charity -- to a certain extent, it sounds as though palliative care is itself capable of certain minor miracles, perhaps because its concentration on the patient's quality of life results in an increase of the patient's actual will to live. But at the same time, the notion that something is being neglected that could keep the patient alive is actually irrelevant to the question of Hospice care -- Hospice care is only warranted if the medical care that can keep the patient alive can no longer be described as "ordinary means." When Pope John Paul II offered personal remarks on the subject of Hospice care in 2004, this was precisely what he emphasized -- he thought it worth remarking that the Church's teaching never deviates broadly from the reasonable medical advice: "Indeed the object of the decision on whether to begin or to continue a treatment has nothing to do with the value of the patient's life, but rather with whether such medical intervention is beneficial for the patient." (John Paul II, 6) For John Paul II, in other words, the…[continue]
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