Compassionate ways to be with family members as they near life's end
Catholic guidance for End of Life Decision Making with Advance Directives
Provides support to Catholics with bioethical consultations, educational opportunities, links to Papal documents, public policy analysis
Available from the National Catholic Bioethics Center and other sources. This is the Pontifical Council for Pastoral Assistance to Health Care Workers
Archbishop Daniel Cronin's study of moral theology of ordinary and extraordinary means for end-of-life decision making.
From the Pontifical Academy for Life:
Dignity Therapy by Harvey Chochinov
How do you maintain dignity at the end of life?
Dignity therapy can change end of life experiences for the dying and those who support them. This book provides key principles to address the most important elements of being human.
Assisted Suicide and Euthanasia
The above link is to the Vatican document on End of LIfe Concerns, with full citations. Below is a simplified summary of some of the key concepts for use in our parishes and communities.
The Good Samaritan
On the Care of Persons in the Critical and Terminal Phases of Life
CONGREGATION FOR THE DOCTRINE OF THE FAITH
- The prohibition of euthanasia and assisted suicide
2. The moral obligation to exclude aggressive medical treatment
3. Basic Care: the requirement of nutrition and hydration
4. Palliative Care
5. The role of the family and hospice
6. Accompaniment and care in prenatal and pediatric medicine
7. Analgesic therapy and loss of consciousness
8. The vegetative state and the state of minimal consciousness
9. Conscientious objections on the part of healthcare workers and of Catholic healthcare institutions
10. Pastoral accompaniment and the support of the sacraments
11. Pastoral discernment towards those who request Euthanasia or Assisted Suicide
12. The reform of the education and formation of the healthcare workers
The Good Samaritan who goes out of his way to aid an injured man (cf. Lk 10:30-37) signifies Jesus Christ who encounters man in need of salvation and cares for his wounds. He is the physician of souls and bodies. How do we make this message concrete today? How do we translate it into a readiness to accompany a suffering person in the terminal stages of life in this world, and to offer this assistance in a way that respects and promotes the intrinsic human dignity of persons who are ill, their vocation to holiness, and thus the highest worth of their existence?
The Church regards scientific research and technology with hope, seeing in them promising opportunities to serve the good of life and the dignity of every human being. In fact, every technical advance calls for growth in moral discernment to avoid an unbalanced and dehumanizing use of the technologies especially in the critical or final stages of human life.
The complexity of healthcare delivery can reduce to a purely technical and impersonal relationship the bond of trust between doctor and patient. In the face of challenges that affect how we think about medicine, the significance of the care of the sick, and our responsibility toward the most vulnerable, the present letter seeks to enlighten pastors and the faithful regarding their questions and uncertainties about medical care, and their spiritual and pastoral obligations to the sick in the critical and terminal stages of life. It is widely recognized that a moral and practical clarification regarding care of these persons is needed.
Care For One’s Neighbor
It is hard to recognize the profound value of human life when we see it in its weakness and fragility. Suffering always raises questions about the meaning of life. The mission of faithful care of human life until its natural conclusion is entrusted to every healthcare worker and is realized through programs of care that can restore, even in illness and suffering, a deep awareness of their existence to every patient. For this reason we begin with a careful consideration of the significance of the specific mission entrusted by God to every person, healthcare professional and pastoral worker, as well as to patients and their families.
The need for medical care is born in the vulnerability of the human condition in its finitude and limitations. Each person's vulnerability is encoded in our nature as a unity of body and soul: we are finite, and yet we have a longing for the infinite and a destiny that is eternal. We depend on material goods and on the mutual support of other persons, and also on our original, deep connection with God. Our vulnerability forms the basis for an ethics of care, especially in the medical field, which is expressed in concern, dedication, shared participation and responsibility towards the women and men entrusted to us for material and spiritual assistance in their hour of need.
The relationship of care discloses the twofold dimension of the principle of justice: to promote human life and to avoid harming another. Jesus transformed this principle into the golden rule “Do unto others whatever you would have them do to you” (Mt 7:12). This rule is presented in traditional medical ethics as “First do no harm”.
Care for life is the first responsibility that guides the doctor in the encounter with the sick. This responsibility exists even when a cure is unlikely or impossible. Medical care attends to the body’s functions, and to the psychological and spiritual well-being of the patient who should never be forsaken. The Good Samaritan not only draws nearer to the man he finds half dead; he takes responsibility for him. He invests in him, not only with the funds he has on hand but also with funds he does not have and hopes to earn in Jericho: he promises to pay any additional costs upon his return. Christ invites us to trust in his invisible grace that prompts us to the generosity of supernatural charity, as we identify with everyone who is ill: “Amen, I say to you, whatever you did for one of these least brothers of mine, you did for me” (Mt 25:40). This expresses a moral truth of universal scope: “we need then to ‘show care’ for all life and for the life of everyone” and thus to reveal the original and unconditional love of God, the source of the meaning of all life.
It is vital to create space for relationships built on the recognition of the fragility and vulnerability of the sick person. Weakness makes us conscious of our dependence on God and invites us to respond with the respect due to our neighbor. At work here is a contemplative gaze that beholds in one’s own existence and that of others a unique and unrepeatable wonder, received and welcomed as a gift. This is the gaze of the one who does not pretend to take possession of the reality of life but welcomes it as it is, with its difficulties and sufferings, and, guided by faith, finds in illness the readiness to abandon oneself to the Lord of life who is manifest therein.
Medicine must accept the limit of death as part of the human condition. The time comes when it is clear that specific medical interventions cannot alter the course of an illness that is recognized to be terminal. This must be communicated to the sick person with great humanity and with openness in faith to a supernatural horizon, aware of the anguish that death involves especially in a culture that tries to conceal it. Physical life is not something to preserve at all costs. Only in reference to the human person in unified totality--a soul which expresses itself in a body and a body informed by an immortal spirit--can the specifically human meaning of the body be grasped.
Responsible communication with the terminally ill person should make it clear that care will be provided until the very end: “to cure if possible, always to care”. The judgement that an illness is incurable cannot mean that care has come at an end. The contemplative gaze calls for a wider notion of care. The objective of assistance must take account of the integrity of the person, and thus use adequate measures to provide the necessary physical, psychological, social, familial and religious support to the sick.
The pastoral care of all - family, doctors, nurses, and chaplains - can help the patient to persevere in sanctifying grace and to die in charity and the Love of God. If faith is absent in the face of the illness, then fear of suffering and death is the main factor driving the attempt to control and manage the moment of death, and indeed to hasten it through euthanasia or assisted suicide.
The Living Experience of the Suffering Christ and the Proclamation of Hope
If the figure of the Good Samaritan throws new light on the provision of healthcare, the nearness of the God made man is manifest in the living experience of Christ’s suffering, of his agony on the Cross and his Resurrection. His experience of pain and anguish resonates with the sick and their families during the long days of infirmity that precede the end of life. Christ’s experience resonates with the sick who are often seen as a burden; their questions are not understood; they often undergo forms of desertion.
In the face of the challenge of illness and the emotional and spiritual difficulties associated with pain, one must know how to speak a word of comfort drawn from the compassion of Jesus on the Cross. It is full of hope – a sincere hope, like Christ’s on the Cross, capable of facing the moment of trial and the challenge of death. In the Cross of Christ are concentrated all the sickness and suffering of the world: all the physical suffering, of which the Cross is the symbol; all the psychological suffering, expressed in the death of Jesus in the darkest of solitude, abandonment and betrayal; all the moral suffering, manifested in the condemnation to death of one who is innocent; all the spiritual suffering, displayed in a desolation that seems like the very silence of God.
At the end of life, people often harbor worries about those they leave behind: about their children, spouses, parents, and friends. This human element can never be neglected and requires a sympathetic response.
Death can become the occasion of a greater hope that, thanks to faith, makes us participants in the redeeming work of Christ. Pain is bearable only where there is hope. The hope that Christ communicates to the sick and the suffering is that of his presence, of his true nearness. Hope is not only the expectation of a greater good, but is a gaze on the present full of significance. In the Christian faith, the event of the Resurrection not only reveals eternal life, but it makes manifest that in history the last word never belongs to death, pain, betrayal, and suffering. Christ rises in history, and in the mystery of the Resurrection the abiding love of the Father is confirmed.
To contemplate the living experience of Christ’s suffering is to proclaim to men and women of today a hope that imparts meaning to the time of sickness and death. From this hope springs the love that overcomes the temptation to despair.
Palliative care in itself is not enough unless there is someone who “remains” at the bedside of the sick to bear witness to their unique and unrepeatable value. For the believer, to look upon the Crucified means to trust in the compassionate love of God. The experience of the Cross lets us to be present to the suffering person as a genuine presence— to speak a word, express a thought, or entrust the anguish and fear one feels. To those who care for the sick, the scene of the Cross provides a way of understanding that even when it seems that there is nothing more to do there remains much to do, because “remaining” by the side of the sick is a sign of love and of the hope that it contains. The proclamation of life after death is not an illusion nor merely a consolation, but a certainty lodged at the center of love that death cannot devour.
The Samaritan’s “heart that sees”: human life is a sacred and inviolable gift
Whatever their physical or psychological condition, human persons always retain their original dignity as created in the image of God. They can live and grow in the divine splendor because they are called to exist in “the image and glory of God” (1 Cor 11:7; 2 Cor 3:18). Their dignity lies in this vocation. God became man to save us, and he promises us salvation and calls us to communion with Him: here lies the ultimate foundation of human dignity.
It is proper for the Church to accompany with mercy the weakest in their journey of suffering and to guide them to salvation. The Church of the Good Samaritan regards “the service to the sick as an integral part of its mission”.
“A heart that sees” is central to the program of the Good Samaritan. He “teaches that it is necessary to convert the gaze of the heart, because many times the beholder does not see. Why? Because compassion is lacking. Without compassion, people who look do not get involved with what they observe, and they keep going; instead people who have a compassionate heart are touched and engaged, they stop and show care. This heart sees where love is needed and acts accordingly.
These eyes identify in weakness God’s call to appreciate that human life is the primary common good of society. Human life is a highest good, and society is called to acknowledge this. Life is a sacred and every human person, created by God, has a transcendent vocation to a unique relationship with the One who gives life. The invisible God out of the abundance of his love offers to each and every human person a plan of salvation that allows the affirmation that: “Life is always a good. This is an instinctive perception and a fact of experience, and man is called to grasp the profound reason why this is so”. God the Creator offers life and its dignity to man as a precious gift to safeguard and nurture, and ultimately to be accountable to Him.
Life is the first good because it is the basis for the enjoyment of every other good including the transcendent vocation to share the trinitarian love of the living God to which every human being is called: The special love of the Creator for each human being confers upon him or her an infinite dignity. The value of life is a fundamental principle of the natural moral law and of the legal order. Just as we cannot make another person our slave, even if they ask to be, so we cannot directly choose to take the life of another, even if they request it. To end the life of a sick person who requests euthanasia does not respect their autonomy. On the contrary this denies the value of both their freedom, now under the sway of suffering and illness, and of their life by excluding any further possibility of human relationship, or of sensing the meaning of their existence. It is to take the place of God in deciding the moment of death. For this reason, abortion, euthanasia and willful self-destruction poison human society, but they do more harm to those who practice them than those who suffer from the injury. They are a supreme dishonor to the Creator.
The Cultural Obstacles that Obscure the Sacred Value of Every Human Life
Among the obstacles that diminish our sense of the profound intrinsic value of every human life, the first lies in the notion of “dignified death” as measured by the standard of the “quality of life,” seen in terms primarily related to economic means, to ‘well-being,’ to the beauty and enjoyment of physical life, forgetting the other, more profound, interpersonal, spiritual and religious dimensions of existence. In this perspective, life is viewed as worthwhile only if it has, in the judgment of the individual or of third parties, an acceptable degree of quality as measured by the possession or lack of particular psychological or physical functions, or sometimes simply by the presence of psychological discomfort. According to this view, a life whose quality seems poor does not deserve to continue. Human life is thus no longer recognized as a value in itself.
A second obstacle that obscures our recognition of the sacredness of human life is a false understanding of “compassion”. In the face of seemingly “unbearable” suffering, the termination of a patient’s life is justified in the name of “compassion”. This so-called “compassionate” euthanasia holds that it is better to die than to suffer, and that it would be compassionate to help a patient to die by means of euthanasia or assisted suicide. In reality, human compassion consists not in causing death, but in embracing the sick, in supporting them in their difficulties, in offering them affection, attention, and the means to alleviate the suffering.
A third factor that hinders the recognition of the value of one’s own life and the lives of others is a growing individualism within relationships, where the other is viewed as a limitation or a threat to one’s freedom. At the root of this attitude is “a neo-pelagianism in which the individual, radically autonomous, presumes to save himself, without recognizing that, at the deepest level of being, he depends on God and others. On the other hand, a certain neo-gnosticism, puts forward a model of salvation that is merely interior, that wishes to free the person from the limitations of the body, especially when it is fragile and ill.
Individualism is at the root of the most hidden problem of our time: solitude or privacy. It is thematized in some contexts even as a “right to solitude”, beginning with the autonomy of the person. In certain conditions of discomfort or sickness, this can be extended to the choice of whether or not to continue living. This “right” underlies euthanasia and assisted suicide. This way of thinking about human relationships and the significance of the good undermines the very meaning of life, allowing its manipulation, even through laws that legalize euthanisia, resulting in the death of the sick. Such actions deform relationships and induce a grave insensibility toward the care of the sick person. In such circumstances, baseless moral dilemmas arise regarding what are in reality simply mandatory elements of basic care, such as feeding and hydration of terminally ill persons who are not conscious.
In this connection, Pope Francis has spoken of a “throw-away culture” where the victims are the weakest human beings, who are likely to be “discarded” when the system aims for efficiency at all costs. This cultural phenomenon, which is deeply contrary to solidarity, John Paul II described as a “culture of death” that gives rise to real “structures of sin” that can lead to the performance of actions wrong in themselves for the sole purpose of “feeling better” in carrying them out. A confusion between good and evil materializes in an area where every personal life should instead be understood to possess a unique and unrepeatable value with a promise of and openness to the transcendent.
The Teaching of the Magisterium
- 1. The prohibitionof euthanasia and assisted suicide
With her mission to transmit to the faithful the grace of the Redeemer and the holy law of God already discernible in the precepts of the natural moral law, the Church is obliged to intervene in order to exclude once again all ambiguity in the teaching of the Magisterium concerning euthanasia and assisted suicide.
The dissemination of medical end-of-life protocols such as the Do Not Resuscitate Order or the Physician Orders for Life Sustaining Treatment – with all of their variations depending on national laws and contexts – were initially thought of as instruments to avoid aggressive medical treatment in the terminal phases of life. Today these protocols cause serious problems regarding the duty to protect the life of patients in the most critical stages of sickness. On the one hand, medical staff feel increasingly bound by the self-determination expressed in patient declarations that deprive doctors of their freedom and duty to safeguard life even where they could do so. On the other hand, concerns have recently arisen about the abuse of such protocols viewed in a euthanistic perspective with the result that neither patients nor families are consulted in final decisions about care. This happens above all in the countries where, with the legalization of euthanasia, wide margins of ambiguity are left open in end-of-life law regarding the meaning of obligations to provide care.
The Church is convinced of the necessity to reaffirm as definitive teaching that euthanasia is a crime against human life because, in this act, one chooses directly to cause the death of another innocent human being. The correct definition of euthanasia depends, not on a consideration of the goods or values at stake, but on the moral object properly specified by the choice of “an action or an omission which of itself or by intention causes death, in order that all pain may in this way be eliminated”. Euthanasia’s terms of reference, therefore, are to be found in the intention of the will and in the methods used. The moral evaluation of euthanasia, and its consequences does not depend on a balance of principles that the situation and the pain of the patient could, according to some, justify the termination of the sick person. Values of life, autonomy, and decision-making ability are not on the same level as the quality of life.
Euthanasia is an intrinsically evil act, in every situation or circumstance. The Church has already affirmed that euthanasia is a grave violation of the Law of God, since it is the deliberate and morally unacceptable killing of a human person. This doctrine is based upon the natural law and upon the written Word of God, is transmitted by the Church’s Tradition and taught by the ordinary and universal Magisterium. Depending on the circumstances, this practice involves the malice proper to suicide or murder. Any formal or immediate material cooperation in such an act is a grave sin against human life. No authority can legitimately recommend or permit such an action. For it is a question of the violation of the divine law, an offense against the dignity of the human person, a crime against life, and an attack on humanity. Euthanasia is an act of homicide that no end can justify. Those who approve laws of euthanasia and assisted suicide, therefore, become accomplices of a grave sin that others will execute. They are also guilty of scandal because by such laws they contribute to the distortion of conscience, even among the faithful.
One who choses with full liberty to take one’s own life breaks one’s relationship with God and with others and renounces oneself as a moral subject. Assisted suicide increases the seriousness of this act because it implicates another in one’s own despair. Another person is led to turn his will from the mystery of God in the theological virtue of hope and thus to reject the authentic value of life and to break the covenant that establishes the human family. Assisting in a suicide is an unjustified collaboration in an unlawful act that contradicts our relationship with God and the moral relationship that unites us with others who share the gift of life and the meaning of existence.
Euthanasia and assisted suicide are always the wrong choice: health care workers – faithful to the task ‘always to be at the service of life and to assist it up until the very end’ – cannot give themselves to any euthanistic practice. Since there is no right to dispose of one’s life arbitrarily, no health care worker can be compelled to execute a non-existent right. Euthanasia and assisted suicide are a defeat for those who theorize about them, who decide upon them, or who practice them.
It is gravely unjust to enact laws that legalize euthanasia or justify and support suicide, invoking the false right to choose a death improperly characterized as respectable only because it is chosen. Such laws strike at the foundation of the legal order: the right to life sustains all other rights, including the exercise of freedom. The existence of such laws deeply wound human relations and justice, and threaten the mutual trust among human beings. The legitimation of assisted suicide and euthanasia is a sign of the degradation of legal systems. Pope Francis recalls that “the current socio-cultural context is gradually eroding the awareness of what makes human life precious. In fact, it is increasingly valued on the basis of its efficiency and utility, to the point of considering as ‘discarded lives’ or ‘unworthy lives’ those who do not meet this criterion. In this situation of the loss of authentic values, the mandatory obligations of solidarity and of human and Christian fraternity also fail. In reality, a society deserves the status of ‘civil’ if it develops antibodies against the culture of waste; if it recognizes the intangible value of human life; if solidarity is factually practiced and safeguarded as a foundation for living together”.
In some countries, tens of thousands of people have already died by euthanasia, and many of them because they displayed psychological suffering or depression. Doctors themselves report that abuses frequently occur when the lives of persons who would never have desired euthanasia are terminated. The request for death is in many cases itself a symptom of disease, aggravated by isolation and discomfort. The factors that largely determine requests for euthanasia and assisted suicide are unmanaged pain, and the loss of human and theological hope, provoked by the often inadequate psychological and spiritual human assistance provided by those who care for the sick. Experience confirms that the pleas of gravely ill people who sometimes ask for death are not to be understood as implying a true desire for euthanasia; in fact, it is almost always a case of an anguished plea for help and love. What a sick person needs, besides medical care, is love, the human and supernatural warmth with which sick persons can and ought to be surrounded by all those close to him or her, parents and children, doctors and nurses.
One experiences pain not just as a biological fact to be managed in order to make it bearable, but as the mystery of human vulnerability in the face of the end of physical life—a difficult event to endure, given that the unity of the body and the soul is essential to the human person.
The “end of life” can be faced with dignity only by the re-signification of the event of death itself—by opening it to the horizon of eternal life and affirming the transcendent destiny of each person. With the help of grace this suffering can, like the suffering of Christ on the Cross, be animated from within with divine charity.
Those who assist persons with chronic illnesses or in the terminal stages of life must be able to “know how to stay”, to keep vigil, with those who suffer the anguish of death, “to console” them, to be with them in their loneliness, to be an abiding with that can instill hope. By means of the faith and charity expressed in the intimacy of the soul, the caregiver can experience the pain of another, can be open to a personal relationship with the weak that expands the horizons of life beyond death, and thus can become a presence full of hope.
Love is made possible and suffering given meaning in relationships where persons share in solidarity the human condition and the journey to God, and are joined in a covenant that enables them to glimpse the light beyond death. Medical care occurs within the therapeutic covenant between the physician and the patient who are united in the recognition of the transcendent value of life and the mystical meaning of suffering. In the light of this covenant, good medical care can be valued, while the utilitarian and individualistic vision that prevails today can be dispelled.
- The moral obligationto exclude aggressive medical treatment
The Magisterium of the Church recalls that, when one approaches the end of earthly existence, the dignity of the human person entails the right to die with the greatest possible serenity and with one’s proper human and Christian dignity intact. To precipitate death or delay it through “aggressive medical treatments” deprives death of its due dignity. Medicine today can artificially delay death, often without real benefit to the patient. When death is imminent, and without interruption of the normal care the patient requires in such cases, it is lawful according to science and conscience to renounce treatments that provide only a precarious or painful extension of life. It is not lawful to suspend treatments that are required to maintain essential physiological functions, as long as the body can benefit from them (such as hydration, nutrition, maintaining normal temperatures, appropriate respiratory support, and the other types of assistance needed to maintain the body and manage pain). The suspension of futile treatments must not involve the withdrawal of therapeutic care. This clarification is now indispensable in light of the numerous court cases in recent years that have led to the withdrawal of care from – and to the early death of–critically but not terminally ill patients, for whom it was decided to suspend life-sustaining care which would not improve the quality of life.
In the specific case of aggressive medical treatment, it should be repeated that the renunciation of extraordinary and/or disproportionate means “is not the equivalent of suicide or euthanasia; it rather expresses acceptance of the human condition in the face of death” or a deliberate decision to waive disproportionate medical treatments which have little hope of positive results. The renunciation of treatments that would only provide a precarious and painful prolongation of life can also mean respect for the will of the dying person as expressed in advanced directives for treatment, excluding however every act of a euthanistic or suicidal nature.
The principle of proportionality refers to the overall well-being of the sick person. To choose among values (for example, life versus quality of life) involves an erroneous moral judgment when it excludes from consideration the safeguarding of personal integrity, the good life, and the true moral object of the act undertaken. Every medical action must always have as its object—intended by the moral agent—the promotion of life and never the pursuit of death. The physician is never a mere executor of the will of patients or their legal representatives, but retains the right and obligation to withdraw at will from any course of action contrary to the moral good discerned by conscience.
- Basic Care: the requirement of nutrition and hydration
A fundamental principle of the assistance of the critically or terminally ill person is the continuity of care for the essential bodily functions. In particular, required basic care for each person includes the administration of the nourishment and fluids needed to maintain the body. When the provision of nutrition and hydration no longer benefits the patient, because the patient’s body either cannot absorb them or cannot metabolize them, their administration should be suspended. In this way, one does not unlawfully hasten death through the deprivation of the hydration and nutrition vital for bodily function, but respects the natural course of the critical or terminal illness. The withdrawal of this sustenance is an unjust action that can cause great suffering to the one who has to endure it. Nutrition and hydration do not constitute medical therapy in a proper sense, which is intended to counteract the pathology that afflicts the patient. They are instead forms of obligatory care of the patient, representing both a primary clinical and an unavoidable human response to the sick person. Obligatory nutrition and hydration can at times be administered artificially, provided that it does not cause harm or intolerable suffering to the patient.
- Palliative care
Continuity of care is part of the enduring responsibility to appreciate the needs of the sick person: care needs, pain relief, and affective and spiritual needs. Palliative medicine is a precious and crucial instrument in the care of patients during the most painful chronic and terminal stages of illness. Palliative care is an authentic expression of the human and Christian activity of providing care, the tangible symbol of the compassionate “remaining” at the side of the suffering person. Its goal is “to alleviate suffering in the final stages of illness and at the same time to ensure the patient appropriate human accompaniment” improving quality of life and overall well-being as much as possible and in a dignified manner. The employment of palliative care reduces the number of persons who request euthanasia. To this end, a resolute commitment is desirable to extend palliative treatments to those who need them.
Palliative care should include spiritual assistance for patients and their families. Such assistance inspires faith and hope in God in the terminally ill as well as their families whom it helps to accept the death of their loved one. It is an essential contribution that is offered by pastoral workers and the whole Christian community. According to the model of the Good Samaritan, acceptance overcomes denial, and hope prevails over anguish. Identification of effective pain relief allows the patient to face the sickness and death without the fear of undergoing intolerable pain. Such care must be accompanied by support to reduce the loneliness that patients may feel.
In times of suffering, the human person should be able to experience a solidarity and a love that takes on the suffering, offering a sense of life that extends beyond death. All of this has a great social importance. A society unable to accept the suffering of its members and incapable of helping to share their suffering, and to bear it inwardly through ‘com-passion’ is a cruel and inhuman society.
It should be recognized, however, that the definition of palliative care has in recent years taken on a sometimes equivocal connotation. In some countries, national laws regulating palliative care (Palliative Care Act) as well as the laws on the “end of life” (End-of-Life Law) provide, along with palliative treatments, something called Medical Assistance to the Dying (MAiD) that can include the possibility of requesting euthanasia and assisted suicide. Such legal provisions are a cause of grave cultural confusion: by including under palliative care the provision of imedical assistance for a voluntary death, they imply that it would be morally lawful to request euthanasia or assisted suicide.
Palliative care to reduce the suffering of gravely ill patients in these regulatory contexts can involve the administration of medications that intend to hasten death, as well as the suspension or interruption of hydration and nutrition even when death is not imminent. These practices are equivalent to a direct action or omission to bring about death and are therefore unlawful. The growing diffusion of such legislation and guidelines is a threat to many people, including vulnerable persons who are being led to choose euthanasia and suicide.
- The roleof the family and hospice
The role of the family is central to the care of the terminally ill patient. In the family a person can count on strong relationships, valued in themselves apart from their helpfulness or the joy they bring. It is essential that the sick do not feel themselves to be a burden, but can sense the intimacy and support of their loved ones. The family needs help and adequate resources to fulfil this mission. Governments should undertake to provide the necessary resources and structures to support the family. Christian-inspired health care facilities should integrate the family’s human and spiritual accompaniment in a unified program of care for the sick person.
Hospice centers which welcome the terminally sick and ensure their care until the last moment of life provide an important and valuable service. The Christian response to the mystery of death and suffering is to provide not an explanation but a Presence that shoulders the pain and opens it to a trusting hope. These centers are an example of genuine humanity in society, sanctuaries where suffering is full of meaning. They must be staffed by qualified personnel, possess the proper resources, and always be open to families. Terminally ill people should be accompanied with qualified medical, psychological and spiritual support, so that they can live with dignity, comforted by the closeness of loved ones, in the final phase of their earthly life. These centers need to continue to be places where the 'therapy of dignity’ is practiced with commitment, thus nurturing love and respect for life. Healthcare workers and pastoral staff, in addition to being clinically competent, should also be practicing an authentic life of faith and hope that is directed towards God, for this is the highest form of the humanization of dying.
- Accompanimentand care in prenatal and pediatric medicine
Regarding the care of neonatal infants and children suffering from terminal chronic-degenerative diseases, or are in the terminal stages of life itself, it is necessary to reaffirm what follows, aware of the need for first-rate programs that ensure the well-being of the children and their families.
Beginning at conception, children suffering from malformation or other pathologies are little patients whom medicine today can always assist and accompany in a manner respectful of life. Their life is sacred, unique, unrepeatable, and inviolable, exactly like that of every adult person.
Children suffering from so-called prenatal pathologies “incompatible with life” – that will surely end in death within a short period of time – and in the absence of fetal or neonatal therapies capable of improving their health, should not be left without assistance, but must be accompanied like any other patient until they reach natural death. Prenatal comfort care favors a path of integrated assistance involving the support of medical staff and pastoral care workers alongside the constant presence of the family. The child is a special patient and requires the care of a professional with expert medical knowledge and affective skills. The empathetic accompaniment of a child, who is among the most frail, in the terminal stages of life, aims to give life to the years of a child and not years to the child’s life.
Prenatal Hospice Centers provide an essential support to families who welcome the birth of a child in a fragile condition. In these centers, competent medical assistance, spiritual accompaniment, and the support of other families, who have undergone the same experience of pain and loss, are an essential resource.
These forms of assistance are particularly necessary for those children who, given the current state of scientific knowledge, are destined to die soon after birth. Providing care for these children helps the parents to handle their grief and to regard this experience not just as a loss, but as a moment in the journey of love which they have travelled together with their child.
Unfortunately the dominant culture today does not encourage this approach. The sometimes obsessive recourse to prenatal diagnosis, along with the emergence of a culture unfriendly to disability, often prompts the choice of abortion, going so far as to portray it as a kind of “prevention.” Abortion consists in the deliberate killing of an innocent human life and as such it is never lawful. The use of prenatal diagnosis for selective purposes is contrary to the dignity of the person and gravely unlawful because it expresses a eugenic mentality. In other cases, after birth, the same culture encourages the suspension or non-initiation of care for the child as soon as it is born because a disability is present or may develop in the future. This utilitarian approach—inhumane and gravely immoral—cannot be countenanced.
The fundamental principle of pediatric care is that children in the final stages of life have the right to the respect and care due to persons. To be avoided are both aggressive medical treatment and unreasonable tenacity, as well as intentional hastening of their death. From a Christian perspective, the pastoral care of a terminally ill child demands participation in the divine life in Baptism and in Confirmation.
It may happen that therapies, designed to combat the pathology from which a child suffers, are suspended during the terminal stage of an incurable disease. The physician may determine that the child’s clinical condition renders these therapies either futile or extreme, and possibly the cause of added suffering. Nonetheless, in such situations the integral care of the child, in its various physiological, psychological, affective, and spiritual dimensions, must never cease. Care means more than therapy and healing. When a therapy is suspended because it no longer benefits an incurable patient, treatments that support the essential bodily functions of the child must continue insofar as the child can benefit from them (hydration, nutrition, maintaining temperature, appropriate respiratory support, and other types of assistance needed to maintain bodily balance and manage pain). The desire to abstain from any overly tenacious administration of treatments deemed ineffective should not entail the withdrawal of care. Routine interventions, like respiratory assistance, can be provided painlessly and proportionately. Thus appropriate care must be customized to the personal needs of the patient, to avoid that a just concern for life does not contrast with an unjust imposition of pain that could be avoided.
Evaluation and management of the physical pain of a new-born or a child show the proper respect and assistance they deserve during the difficult stages of their illness. Maintaining the emotional bond between the parent and the child is an integral part of the process of care. The connection between caregiving and parent-child assistance that is fundamental to the treatment of incurable or terminal pathologies should be favored as much as possible. In addition to emotional support, the spiritual moment must not be overlooked. The prayer of the people close to the sick child has a supernatural value that surpasses and deepens the affective relationship.
The ethical/juridical concept of “the best interest of the child” – when used in the cost-benefit calculations of care– can in no way form the foundation for decisions to shorten life in order to prevent suffering if these decisions envision actions or omissions that are euthanistic. The suspension of disproportionate therapies cannot justify the suspension of the basic care, including pain relief, necessary to accompany these little patients to a dignified natural death, nor to the interruption of that spiritual care offered for one who will soon meet God.
- Analgesic therapy and loss of consciousness
Some specialized care requires, on the part of the healthcare workers, a particular attention and competence to attain the best medical practice from an ethical point of view, with attention to people in their concrete situations of pain.
To ease a patient’s pain, analgesic therapy employs pharmaceutical drugs that can induce loss of consciousness (sedation). While a deep religious sense can make it possible for a patient to live with pain through the lens of redemption as a special offering to God, the Church nonetheless affirms the moral liceity of sedation as part of patient care in order to ensure that the end of life arrives with the greatest possible peace and in the best internal conditions. This holds also for treatments that hasten the moment of death (deep palliative sedation in the terminal stage), always, to the extent possible, with the patient’s informed consent. From a pastoral point of view, prior spiritual preparation of the patients should be provided in order that they may consciously approach death as an encounter with God. The use of analgesics is, therefore, part of the care of the patient, but any administration that directly and intentionally causes death is a euthanistic practice and is unacceptable. The sedation must exclude, as its direct purpose, the intention to kill, even though it may accelerate the inevitable onset of death.
In pediatric settings, when a child is unable to understand, it must be stated that it would be a mistake to suppose that the child can tolerate the pain, when in fact there are ways to alleviate it. Caregivers are obliged to alleviate the child’s suffering as much as possible, so that he or she can reach a natural death peacefully, while being able to experience the loving presence of the medical staff and above all the family.
- The vegetative stateand the state of minimal consciousness
Other relevant situations are that of the patient with the persistent lack of consciousness, the so-called “vegetative state” or that of the patient in the state of “minimal consciousness”. It is always completely false to assume that the vegetative state, and the state of minimal consciousness, in subjects who can breathe autonomously, are signs that the patient has ceased to be a human person with all of the dignity belonging to persons as such. On the contrary, in these states of greatest weakness, the person must be acknowledged in their intrinsic value and assisted with suitable care. The fact that the sick person can remain for years in this anguishing situation without any prospect of recovery undoubtedly entails suffering for the caregivers.
The patient in these states has the right to nutrition and hydration, even administered by artificial methods that accord with the principle of ordinary means. In some cases, such measures can become disproportionate, because their administration is ineffective, or involves procedures that create an excessive burden with negative results that exceed any benefits to the patient.
The obligation of caregivers includes not just the patient, but extends to the family or to the person responsible for the patient’s care, and should be comprised of adequate pastoral accompaniment. Adequate support must be provided to the families who bear the burden of long-term care for persons in these states. The support should seek to allay their discouragement and help them to avoid seeing the cessation of treatment as their only option. Caregivers must be sufficiently prepared for such situations, as family members need to be properly supported.
- Conscientious objectionson the part of healthcare workers and of Catholic healthcare institutions
In the face of the legalization of euthanasia or assisted suicide, formal or immediate material cooperation must be excluded. Such situations offer specific occasions for Christian witness where “we must obey God rather than men” (Acts 5:29). There is no right to suicide nor to euthanasia: laws exist, not to cause death, but to protect life and to facilitate co-existence among human beings. It is therefore never morally lawful to collaborate with such immoral actions or to imply collusion in word, action or omission. The one authentic right is that the sick person be accompanied and cared for with genuine humanity. Only in this way can the patient’s dignity be preserved until the moment of natural death. “No health care worker, therefore, can become the defender of a non-existing right, even if euthanasia were requested by the subject in question when he was fully conscious”.
The general principles regarding cooperation with evil, that is, with unlawful actions, are thus reaffirmed: “Christians, like all people of good will, are called, with a grave obligation of conscience, not to lend their formal collaboration to those practices which, although allowed by civil legislation, are in contrast with the Law of God. In fact, from the moral point of view, it is never licit to formally cooperate in evil. This cooperation occurs when the action taken, either by its very nature or by the configuration it is assuming in a concrete context, qualifies as direct participation in an act against innocent human life, or as sharing the immoral intention of the principal agent. This cooperation can never be justified neither by invoking respect for the freedom of others, nor by relying on the fact that civil law provides for it and requires it: for the acts that each person personally performs, there is, in fact, a moral responsibility that no one can ever escape and on which each one will be judged by God himself (cf. Rm 2:6; 14:12)”.
Governments must acknowledge the right to conscientious objection in the medical and healthcare field, where the principles of the natural moral law are involved and especially where in the service to life the voice of conscience is daily invoked. Where this is not recognized, one may be confronted with the obligation to disobey human law, in order to avoid adding one wrong to another, thereby conditioning one’s conscience. Healthcare workers should not hesitate to ask for this right as a specific contribution to the common good.
Healthcare institutions must resist the strong economic pressures that may sometimes induce them to accept the practice of euthanasia. If the difficulty in finding necessary operating funds creates an enormous burden for these public institutions, then the whole society must accept an additional liability in order to ensure that the incurably ill are not left to their own or their families’ resources. All of this requires that episcopal conferences and local churches, as well as Catholic communities and institutions, adopt a clear and unified position to safeguard the right of conscientious objection in regulatory contexts where euthanasia and suicide are sanctioned.
- Pastoral accompanimentand the support of the sacraments
Death is a decisive moment in the human person’s encounter with God the Savior. The Church is called to accompany spiritually the faithful in the situation, offering them the “healing resources” of prayer and the sacraments. Helping the Christian to experience this moment with spiritual assistance is a supreme act of charity. Because “no believer should die in loneliness and neglect”, it encompasses the patient with the solid support of human, and humanizing, relationships to accompany them and open them to hope.
The parable of the Good Samaritan shows what the relationship with the suffering neighbor should be, what qualities should be avoided – indifference, apathy, bias, fear of soiling one’s hands, totally occupied with one’s own affairs – and what qualities should be embraced – attention, listening, understanding, compassion, and discretion.
The family has always played an important role in care, because their presence sustains the patient, and their love represents an essential therapeutic factor in the care of the sick person.
Taking care of others, or providing care for the suffering of others, is a commitment that embraces not just a few but the entire Christian community. Saint Paul affirms that when one member suffers, it is the whole body that suffers (cf. 1 Cor 12:26) and all bend to the sick to bring them relief. Everyone, for his or her part, is called to be a “servant of consolation” in the face of any human situation of desolation or discomfort.
Pastoral accompaniment involves the exercise of the human and Christian virtues of empathy, of compassion, of bearing another’s suffering by sharing it, and of the consolation, of entering into the solitude of others to make them feel loved, accepted, accompanied, and sustained. The ministry of listening and of consolation that the priest is called to offer, which symbolizes the compassionate solicitude of Christ and the Church, can and must have a decisive role. In this essential mission it is extremely important to bear witness to and unite truth and charity with which the gaze of the Good Shepherd never ceases to accompany all of His children.