Hospice Care and Catholic Bioethics: Are They Compatible?

Introduction: Framing the Question

Is hospice care consistent with Catholic bioethics? Chapple, in her discussion of the topic 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 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 the Terri Schiavo case, which brought Catholic teachings about medical intervention at the end of life into national debate and discussion. The Schiavo case centered on a straightforward question 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 broader Catholic teachings about 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 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.

Defining Hospice Care and Its Ethical Stakes

To begin, 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 their 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, left untreated. For this reason we must ask whether hospice in some way represents a withholding of necessary medical treatment, and if it is in any way a moral wrong, it must be a sin of omission rather than commission: not what a person does so much as what a person fails to do.

To a certain degree, this recalls 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 likely. 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 — at the level of a hospital bed and a feeding tube. It is worth noting that the Catechism of the Catholic Church actually distinguishes 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:

"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 2278)

The Catechism on Ordinary and Extraordinary Means

The distinction between hospice care and straightforward euthanasia is captured in a single phrase: in hospice care "one does not will to cause death," whereas the removal of the feeding tube from Terri Schiavo was intended for no other purpose than to cause death. This becomes the ethical sticking point for questions of hospice care within specifically Catholic teaching. It is worth noting that the Catechism goes on to state 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, Catholic teaching on hospice is automatically shaped by the question of which patients would be considered eligible for hospice care under Catholic standards. Terri Schiavo's feeding tube was not particularly burdensome, dangerous, or extraordinary, and it served its function of preventing her from starving to death. Catholic standards of care therefore insisted upon the maintenance of that feeding tube as ethically necessary. But what if the only care available to halt the progress of a disease were dangerous or experimental — or what if no adequate care actually existed? This situation is quite common with certain types of cancer. There are not many effective medications to combat stage-four adenocarcinoma of the lung, and a cancer as far advanced as stage four would require such high doses of chemotherapy that the treatment may well kill the patient sooner than the disease. This is precisely what the Catechism has in mind when it absolves the patient from any ethical necessity to pursue "extraordinary means" to stay alive.

As Chapple notes, and as other proponents of hospice care have argued, hospice is not the withholding or abandoning of medical care — 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 care stops; instead, the care becomes palliative, intended to improve the quality of life for the patient, with goals such as reduction of pain and retention of mobility.

Conclusion: Hospice Care Within Catholic Ethics

In short, Chapple's argument is sound: hospice care is ultimately consistent with Catholic bioethics, or it can be. But it is worth noting that hospice care does court some of the paradoxes and difficulties in Catholic bioethics — particularly the recognition on the Church's part that eligibility for hospice care is determined by doctors on the basis of whether medicine has little or no constructive function remaining. Hospice care is not an abandonment of care; it is the ethical obligation to provide a special kind of charity for the dying, and it is medical care aimed at being palliative rather than curative.

Yet it is not hard to see the ways in which hospice care courts conceptual controversy within the Catholic bioethical belief system. To a certain extent, hospice can be seen as taking a step toward the normalization of assisted suicide by normalizing the idea that in certain cases, medical science has very little concrete to offer a patient. Yet this happens to be a fact: late-stage cancers, for example, do not call forth a range of potential concrete medical treatments. In many cases, the patient may be persuaded to take part in the medical trial of an experimental drug simply because no otherwise persuasive treatment exists. This is where the Church's reminder that "extraordinary" medical means are not an obligation in medical ethics proves handy — nobody can be obliged to submit to an untried experimental drug, not even for a fatal illness.

As a result, hospice care is the ordinary charity that replaces the extraordinary excesses of medicine, which might well make the patient's few remaining weeks highly unpleasant. The pivotal thing to remember is that hospice care is, of necessity, a last resort — it is by no means an easeful form of slow suicide, but instead a concerted effort to maintain dignity and normality at the end of life. Thus, the ethical obligation to stay alive can, to a certain extent, be passed over in recognition of death's inevitability — as long as one is not colluding with death itself in any way, the permissible moral leeway is granted.

References

Catechism of the Catholic Church. Accessed 18 March 2013 at:

Chapple, HS. "Hospice care." In Furton, EJ, Cataldo PJ, and Moraczewski AS. Catholic Health Care Ethics: A Manual for Practitioners. 2nd Edition. Philadelphia: National Catholic Bioethics Center, 2009.

Gawande, A. "Letting Go: What Should Medicine Do When It Can't Save Your Life?" The New Yorker. August 2, 2010. Accessed 18 March 2013.

Pope John Paul II. "To Participants in the 19th International Conference of the Pontifical Council for Health Pastoral Care." L'Osservatore Romano, English language edition. 24 November 2004. p. 6.