ETHICS OF PROLONGING LIFE AND EUTHANASIA

Source: Lorenzo Cantoni, Giovanna Fravolini, Cristianità n. 249 (1996).

The issue when to prolong and when to allow to die is debated heavily in many courts,
hospitals, and different countries around the world. In the light of this situation, we shall study
the history and theology of the Catholic teaching on this issue so as to develop a consensus among
those who accept the teaching of the Church, as well as among those who primarily follow the
ethical norms of our pluralistic society.

Before we plunge ourselves on the issue of prolonging life, it is best that we more or less
level off on some terminologies relative to the question of preserving life and ending it. After this
terminological clarification we shall discuss a particular on which to hinge the history and ethical
principles involve on the question of prolonging life or ending it.

1. Euthanasia: A Terminological Clarification

Euthanasia has been misunderstood in many medical cases involving decision on whether
to preserve life or not. There are many factors affecting the debate on euthanasia. But before
discussing the on-going debate on euthanasia and the issues raised therein, it is necessary that we
understand some basic concepts relative to it.

The word Euthanasia originated from the Greek language: eu means "good" and thanatos
means "death". The meaning of the word is the intentional termination of life by another at the
explicit request of the person who dies. That is, the term euthanasia normally implies that the
person who wishes to commit suicide must initiate the act. However, some people define
euthanasia to include both voluntary and involuntary termination of life. Like so many
moral/ethical/religious terms, "euthanasia" has many meanings. The result is mass confusion.

It is important to differentiate among a number of vaguely related terms:

1) Passive Euthanasia: Hastening the death of a person by withdrawing some form of

support and letting nature take its course. It may also mean the lightening of death through
omission or discontinuation of life-prolonging measures. For example: removing life support
equipment (e.g. turning off a respirator) or stopping medical procedures, medications etc., or
stopping food and water and allowing the person to dehydrate or starve to death, not delivering
CPR (cardio-pulmonary resuscitation) and allowing a person, whose heart has stopped, to die.
Perhaps the most common form of passive euthanasia is to give a patient large doses of morphine
to control pain, in spite of the likelihood of the pain-killer suppressing respiration and causing
death earlier than it would otherwise happened.

These procedures are performed on terminally ill, suffering persons so that natural death
will occur sooner. It is also done on persons in a persistent vegetative state (PVS) - individuals
with massive brain damage who are in a coma from which they cannot possibly regain
consciousness.
Ethics of Prolonging Life and Euthanasia 2

Passive euthanasia is an ambiguous term. It can mean bringing about death by omission
where treatment is morally required and where the intention is to cause death. It can also mean
omitting treatment which is not morally required with the result that the person dies but where
there is no intention to kill.

2) Active Euthanasia: This involves causing the death of a person through a direct action,
in response to a request from that person. The Pontifical Council Cor Unum strongly urges that
among Catholics the term “euthanasia” be reserved to mean direct and active form of causing
death so as to avoid ambiguities. A well-known example was the mercy killing in 1998 of a
patient with Alzheimer disease (Lou Gehrig's Disease) by Dr. Jack Kevorkian, a Michigan
physician. He injected controlled substances into the patient, thus causing his death. Charged
with 1st degree murder, the jury found him guilty of 2nd degree murder in March 1999.

3) Physician Assisted Suicide: A physician supplies information and/or the means of

committing suicide (e.g. a lethal dose of sleeping pills, or carbon monoxide gas) to a person, so
that they can easily terminate their own life. The term "voluntary passive euthanasia" (VPE) is
becoming commonly used.

One writer suggests the use of the verb "to kevork". This is derived from the name of Dr.
Kevorkian, who has promoted VPE and assisted at the deaths of hundreds of patients. Originally
he hooked his patients up to a machine that delivered measured doses of medications, but only
after the patient pushed a button to initiate the sequence. More recently, he provided carbon
monoxide and a facemask so that his patient could initiate the flow of gas.

4) Involuntary Euthanasia: This term is used by some to describe the killing of a person in
opposition to their wishes. It is basically a form of murder.

2. Matters Relative to the On-going Debates on Euthanasia

1. Misconception between allowing the person die and ending the person’s life by an overt
act. One common misconception about euthanasia is that there is no difference between allowing
a person to die and the ending the person’s life by overt action. Overt actions can be the taking of
lethal amounts of medication, the administration of poisonous gases, pills or intravenous
solutions, or overt killing such as suffocating and shooting. There is faulty thinking in this
misconception because what makes euthanasia euthanasia is not the fact the person has died but
rather the direct positive intervention.

2. Large dose of painkiller to alleviate suffering and lethal dose of medicine to end the life
of the patient. Another misconception about euthanasia is to see no difference between giving a
person a large dose of a painkiller to ease his/her suffering and giving the patient a lethal dose of
any kind of medication for the purpose of causing the person’s death. These two acts are
significantly different based on the intentions which motivate them. In the first instance, the
intention is to ease the person’s pain by providing sufficient medication is a good one even if
there is an unintended side effect—the person’s respiration is suppressed and he/she dies. On the
other hand, to give a fatal dose of medication to a person for the purpose of ending the life of that
person constitutes an act of killing. Killing by administering medicine so as to cause death is
Ethics of Prolonging Life and Euthanasia 3

definitely different from providing pain medication which might result in suppression of
respiration and, indirectly, death.

3. Change in the nature of the mission of medicine. In the classical tradition of Western
medicine dating back to the Hippocratic Oath, the responsibility of a physician has consistently
been to do whatever is possible to bring about cures for the sick people or to care and comfort
people whose illness puts them beyond cure.

I will apply measures for the benefit of the sick according to my ability and judgment: I
will keep them from harm and injustice.

Connected to this is this principle: As to diseases, make a habit of two things—to help, or
at least not harm. If we look at the role of nurses it is understood in terms of education,
assistance, care and supervision of the patient. A part of the movement toward euthanasia calls
for the expansion of the roles of physicians and nurses. That will include allowing them to use
their expertise in assisting terminally ill people in ending their lives. What is behind this way of
thinking is the reality that there is no better person to calculate the right amount of medication or
to finish the job of terminating life than someone in the medical practice. His/Her learning
qualifies him/her for these tasks. If we are to include in the responsibilities of physicians and
nurses a participation in euthanasia what happens is that there will be a radical change in very
nature of the practices of both doctors and nurses. In short, there will be a radical change in the
nature of the mission of medicine.

4. The patient’s autonomy. In the past the physician-patient relationship was characterized
by the benevolence of the physician toward the patient. The system considered the doctor in a
position of superiority relative to the patient, therefore the patient’s preference and right to self-
determination were not given much interest. However, there is now a significant change in world
and culture of medicine which results in the patient getting used to deciding what kind of care
they want or not. Within this new development it is understandable the request made by a patient
to be assisted in bringing about death due to his/her burden in his/her ailment.

5. Change of locus of death. In the past most people died at home. Today, 80% of people
die in hospitals due to chronic or terminal ailment. Since many die in institutions, apparatuses of
technology accompany their death. These (tubes, machines, monitors, catheters, etc.) are
employed to wonders to a sick and dying person. However, they nevertheless become
burdensome and nuisance for a very sick or dying patient. Thus there is established a thin line
between a technologically burdened dying and self-deliverance. Many will see that there is a
growing support for euthanasia because they want to avoid the futile and burdensome technology.

6. Sufferings caused by debilitating diseases. AIDS, some forms of cancer and

debilitating diseases bring to the patient dreadful diminished capacities. People afflicted by AIDS
and cancer tend to be very sick, frail and uncomfortable at the end of unsuccessful treatments.
This situation brings to the fore the issue of speeding up the dying process.

7. Pro-euthanasia groups. Hemlock Society in the United States and other interest groups
and vocal spokespersons continuously bombard the media promoting pro-euthanasia views. They
work towards legalization of euthanasia or physician-assisted suicide and physician-aided dying.
Ethics of Prolonging Life and Euthanasia 4

8. Secularization. Secularization has continuously imbued society not only with

consumerist mentality but an “instant-thing” consciousness that wants to get thing as easily as
possible. This has affected most aspects of life and is carried realized with due regard to the
transcendent reality. People no longer are able to see the connection of the divine reality and the
temporal reality so that obligations derived from the later are no longer accepted. Central in
secularization is the freedom of the secular person to act in accord with the subjective reason and
choose and die in the fashions that they feel suit them.

9. Disappearance of taboos. So many changes have happened in the recent past that there
is much more freedom today that there was in the past. Because of this many taboos have been
flushed out the consciousness of people. Thou shall not kill, a biblically rooted taboo or norm,
loses its force for those suffering from lingering illnesses or for those chronically or terminally ill
patients. Silence with regard to the taboos is now replaced by people’s freedom to make them
relative.

3. A Case Study

To focus ourselves more on the complexity of the issue of euthanasia, I am presenting a

concrete medical case. This case was filed in the U.S. court for a decision.

Marcia Gray, 49 years old, fell into a coma after having serious stroke causing cerebral
hemorrhage. She was given food and liquids through the jejunostomy tube, that is a tube
surgically placed into the small intestine. The administration of food and liquid is referred to as
nutrition and hydration. She was in a state of unconsciousness from which there was no hope that
she could recover. In short, she was in a permanent vegetative state (PVS). The procedure
involved considerable cost. The ethical question which had to be faced by her family: Is morally
required that this procedure be continued.

4. A Moral-Theological Position on the Case

Within the Catholic tradition there seems to be four positions on the question of providing
nutrition and hydration:

1) Nutrition and hydration, may, in certain circumstances be considered extraordinary means,

because they are useless to the person. Therefore, it is not morally right to provide them, or to
withdraw them when their uselessness is clear (McCormick, Paris, etc.).

This view does not ask whether or not a particular life is good for society or for others, but
whether it is good for the person who is living that life. In this context it could be said that a
certain kind of life is useless for the person living it, in the sense, for example, that this life has
already fulfilled its potential and merely existing longer can contribute nothing to the person’s
attainment of life’s goal. Similarly it could be said, according to this view, the burden which
must be taken into account is the burden the person would experience in striving to attain the
purpose of life under the conditions impose by his/her disability and sickness.

2) Nutrition and hydration may in certain circumstances be considered extraordinary means and
may, in principle, be withdrawn. But there are practical, prudential reasons for prohibiting
Ethics of Prolonging Life and Euthanasia 5

such withdrawal. For example, such withdrawal could be interpreted as euthanasia. Thus such
a withdrawal could give scandal. The rule allowing withdrawal could be misused (to justify
euthanasia), families might feel great guilt if they consented to such withdrawal (McFadden).

3) If the provision of nutrition and hydration is really useless or excessively burdensome, then
these means may be rightly withheld or withdrawn, provided this omission does not carry out a
proposal to end the person’s life. What counts in this position is that the means impose a
burden. What the person withholding or withdrawing the nutrition or hydration must intend
and choose is not to inflict on another person procedures which (a) can do nothing to remove
the causes of that other’s disabilities or sufferings (useless), or which (b) can only cause
burden to the other (burdensome) (Boyle, May, Grizes, etc.).

This view rejects the quality of life view completely, that is, life itself may be of lesser value
that other lives, or of less value, or useless to the person living that life. Life is not a good for
the person but rather life is a basic good (constitutive goodness of life), a good for the person.
Because of life’s constitutive goodness, life can never be said to be useless. Preserving life is
therefore always a serving of the good. Furthermore, procedures of nutrition and hydration do
confer a good on the patients in that they prevent their dying from starvation or dehydration.
However, it is clearly recognize that the means of providing nutrition and hydration could very
well have side-effects, such as pain and discomfort, which could make them excessively
burdensome. They could then, be legitimately withdrawn, or even not begun, on the grounds
of excessive burden.

4) Nutrition and hydration must be provided to all patients, including the terminally ill, up to the
actual point of death. This is an extreme view which is not consistent with the Catholic
tradition or sustainable with reasonable argument.

Based on an interpretation of the Catholic tradition, a theological position was presented.

1) Marcia Gray’s prognosis is that there is not reasonable hope for recovery. She is in a
permanent vegetative state. Therefore, treatments which are being provided her, even
those which supply nutrition and hydration artificially, offer no reasonable hope of
benefit to her.
2) This lack of reasonable hope of benefit renders the artificially invasive medical
treatments futile and thus, extraordinary, disproportionate and burdensome.
3) The continuation of such medical treatments is causing significant and precarious
economic burden to Marcia Gray’s family.
4) It must be clear that the primary intention of removing what was competently judged
to be extraordinary means of artificially prolonging the patient’s natural life is to
alleviate the burden and suffering and not to cause her death.
5) Even after the removal of such extraordinary means of prolonging life, the patient has
the right, because of her dignity as a human person, to proper care and the provision
of comfort.
6) If these conditions are fulfilled, the removal of hydration and nutrition is not
inconsistent with the moral teaching of the Roman Catholic Church and would not
constitute euthanasia.

The essential points in the argument are the following:

Ethics of Prolonging Life and Euthanasia 6

1. There is no reasonable hope of recovery.

2. Therefore, any treatments that might be used offer no hope of benefit.
3. This applies also to those procedures which are supplying nutrition and hydration.
4. Because these treatments, which are artificially invasive, are futile, they are
extraordinary, disproportionate and unduly burdensome.
5. The provision of the procedures causes economic burden to the family.
6. Such treatments may be removed, provided the primary intention is to alleviate the
burden and suffering of the patient and not to cause death.

Analyzing the steps, there are still some things not clear. Here are clarifications that one
may possibly raise on the issue:

1) Is providing the patient with food and water a treatment that can therefore be judged in
the same way as other treatments, or is it something other than treatment? Behind this
question is the emotional issue of starving the patient to death inasmuch as no nutrition
or hydration will be given her with the withdrawal of the procedures. Is this not an act
of murder?
2) Does it make a morally significant difference that the procedure is artificial? What if
food and water were given to the patient not by tube but in a natural non-artificial
way? For example, if she could be fed with a spoon, and supplied with natural rather
than artificial nourishment, would that make a difference?
3) What is the significant point really the artificiality in the treatment or the burden
caused to the patient? Jejunostomy involved surgery and bodily invasion and therefore
burdensome for the patient. Are these burdensome reasons that which count rather
than mere artificiality of the treatment? Does artificiality in the treatment make a
difference or not?
4) It is argued that the procedures are extraordinary, and disproportionate because the
procedures are futile, what is meant by extraordinary and disproportionate?
5) Moreover, it is argued that the procedures are unduly burdensome, what is meant by
unduly here? There seems to be a suggestion that there could be cases where the
procedures or treatments caused burdens to the patient but these burdens were not
unduly burdensome. In such a case, would it be morally obligatory to have the
procedures or treatments?

The explanation of the case and our analysis of it seem to lead to legalistic display of
knowledge. This is not our intention here. What I intend to do through the case presentation and
its analysis is to lead to the question of euthanasia. Is the withdrawal of treatments in the case of
Marcia Gray constitutive of euthanasia or not?

There are three fundamental principles of the tradition relative to life: 1) to foster it and to
prohibit direct killing; 2) another person may not be killed, even where the killing is intended as a
means to preventing further suffering; 3) we are required to overcome the causes of suffering
(where we cannot remove the suffering and all we can do only causes more suffering to the
person, we are not therefore required to do the treatment). These principles are crucial because
they summarize the position of the Catholic tradition with regard to life preservation.
Ethics of Prolonging Life and Euthanasia 7

The Value of Human Life

1. Life is a gift from God. God gave us the gift of human life to show forth his goodness
and love (Gn 1). We, in turn, show our love for God by respecting and fostering that gift of
human life. Although we are called to life beyond human life, we do not disdain the gift of
human life or reject it to hasten our advance toward eternal life (Lk 8:11). From this reality we
can derive two principles relative to question of the value of life: the principle of stewardship and
the principle of the inviolability of life.

The principle of stewardship upholds that human life comes from God and therefore no
person no matter who he/she is the master of his/her own body. No one may dispose of his/her
life or another’s. It violates God’s dominion over life.

The principle of inviolability of life affirms the sacredness of life and therefore the duty of
custodianship. Recently this is called a right. Hence the ideas of the right to life and right to
health. Thus killing an innocent victim is considered wrong because it constitutes a violation of
his/her right to life.

2. Life must be prolonged as an expression of love of God, our neighbors and ourselves.
As Jesus taught, love for God leads us not only to love ourselves, but to love others as well (Mt
22:37). One way to show our love for God, for ourselves, and for others is to prolong human life.
Thus it is not an act of responsible human love to willfully and directly end one's own life or the
life of another. Suicide and euthanasia have always been denounced by Christians because these
acts are considered to be a serious violation of love for God.

3. Human life is not an ultimate good, it is a fundamental good. Although human life is a
great good upon which many other goods depend, sacred Scripture indicates it is not the ultimate
good.1 At times, the choice of another good may justify the indirect surrender of human life. In
these circumstances, one does not choose death, but allows death to ensue because another greater
good is chosen directly. Jesus on the cross, for example, chose to do the Father's will and freely
gave his human life for the salvation of the world. Martyrs surrender their lives rather than deny
God in their hour of crisis. Thus Christians have always maintained that life could be surrendered
indirectly, if continuing to live would impede the response of love to God.

Human life, then, is a relative good in regard to the absolute precept of Jesus: "Love God,
and love your neighbor as yourself." Although prolonging life is usually a value because living
humanly draws us closer to God, on some occasions prolonging life becomes an impediment or
obstacle to returning God's love.

1
"Relectio IX; de Temperentia," Relectiones Theologicia, 1587: cf. Relecciones Teologicas, edición critica,
Madrid: Imprenta La Rafa, 1933-35, Vol. III. The Relectio was a lecture that Vittoria, the preeminent theologian at
the University of Salmanca, Spain, would give at the beginning of the school year. These lectures always treated a
difficult, contemporary ethical issue. For example, he considered the rights of the natives in the New World, the
rights of the Spanish to convert the natives, the norms for international law, and other timely topics. Hence, we may
presume that in his time the question of prolonging life was as disputed as it is in our time.
Ethics of Prolonging Life and Euthanasia 8

Sanctity of Life

When we talk about the sanctity of life we are also denoting the inviolability of human
life. Let us clarify what do we really mean when we say that life is sacred and therefore it must
be respected.

The Instruction n Respect for Human Life in Its Origin and on the Dignity of Procreation
(Donum Vitae) gives the criterion why life must be respected:

From the moment of conception, the life of every human being is to be respected in an
absolute way because (1) man is the only creature on earth that God has "wished for
himself"(16) and (b) the spiritual soul of each man is "immediately created" by God (17);
(c) his whole being bears the image of the Creator (Introduction, no. 5)

Another reason for respect of life is the idea of dominion:

God alone is the Lord of life from its beginning until its end: no one can, in any
circumstance, claim for himself the right directly to destroy an innocent human being
(Introduction, no. 5).

Life has a value because on it all the values of the human are based and developed:
Physical life, with which the course of human life in the world begins, certainly does not
itself contain the whole of a person's value, nor does it represent the supreme good of
man, who is called to eternal life. However, it does constitute in a certain way the
"fundamental value of life, precisely because upon this physical life all the other values
of the person are based and developed (Introduction, no. 4).

Life is also sacred and therefore ought to be respected because every person has a right to
life from conception to death:

The inviolability of the innocent human being's right to life "from the moment of
conception until death"(14) is a sign and requirement of the very inviolability of the
person to whom the Creator has given the gift of life (Introduction, no. 4).

Human life must be absolutely respected and protected from the moment of conception;
and therefore from the same moment his rights as a person must be recognized, among
which in the first place is the inviolable right of every innocent human being to life (1,
no. 1).

Sanctity of life is also used to mean equality of life. All lives of humans must be
considered of equal value and none judged to be less value that another. Sanctity of life does not
mean vitalism, that is, the ethical position, which holds that human life, must be preserved at all
cost in all circumstances.

Some of these statements belong to the level of faith/vision and they do not immediate
pertain to the area of ethical analysis. Therefore to say that life is sacred in the sense of having
special relationship with God does not immediately produce the ethical conclusion that life must
not be immediately taken. There is still a need for further argument to connect the two levels.
Likewise, to say that God has dominion over life does not signify that life may not be taken
Ethics of Prolonging Life and Euthanasia 9

directly. It simply says that one’s dominion over life has limits but it does not tell us where the
limits of human stewardship and dominion are. To the statement that life is a fundamental value
and not a supreme value expresses a hierarchy of values and it does not of itself provide ethical
norms.

Teaching of Theologians of the Past

From the earliest centuries of the Church, when discussing acts that are opposed to care
for life as an act of love for God, theologians focused on murder, suicide, and euthanasia, which
by act or omission were intended to cause death directly.

St. Thomas considers killing an innocent person wrong (II-II, q. 64, a. 6) due to the
following reasons:

1) Because we ought to love nature made by God, in killing we corrupt nature.

2) In killing we deprive the community of the good of that one’s presence and collaboration.
3) God has dominion over life and humans lack that dominion over life and therefore must act as
its steward or custodian only.
4) In killing one harms the person he/she ought to love and therefore he/she acts against charity.
5) Killing is against justice too because the killer injures one who does not deserve it.

He also sees killing oneself as illicit. He gives three reasons why suicide is wrong:

1) Every person loves him/herself and has the natural inclination to conserve him/herself and to
resist what threatens to destroy him/her. Therefore to kill oneself is against the natural
inclination and against the love for self.
2) Every person is part of the community; so that what he/she is belong to the community. To
commit suicide is to do injury to the community.
3) Life is a gift from God and subject to him. Thus, a person who commits suicide sins against
God. His/her life belongs to God.

But as the possibility of prolonging life through medicine or surgery increased,

theologians started questioning how much effort one should expend to stay alive. Would it be a
sin to reject efforts to prolong life if those efforts involved grave suffering, prohibitive expenses,
or other serious burdens? Are there situations when choosing to avoid pain, suffering, or
economic burden would bring about death only indirectly? In the sixteenth century, theologians
began to discuss the questions: When would it not be suicide to allow oneself to die? When
would it not be euthanasia to allow another to die?

The first explicit discussion of these questions is by Francisco di Vittoria, a Spanish

Dominican theologian whose Relationes Theologicae were originally published in 1557, 10 years
after his death. In this work, Vittoria considered the moral obligation to use food to prolong life.
He declared:

If a sick man can take food or nourishment with a certain hope of life, he is required to
take food as he would be required to give it to one who is sick. However, if the
depression of spirits is so severe and there is present grave consternation in the appetitive
power so that only with the greatest effort and as though through torture can the sick man
Ethics of Prolonging Life and Euthanasia 10

take food, this is to be reckoned as an impossibility and therefore, he is excused, at least

from mortal sin.2

Notice that Vittoria does not say a person in good health may starve himself because he is
tired of living. Nor does he allow much leeway if the means (food) are effective ("a certain hope
of life") and do not involve a grave burden. But he suggests that if a person is so sick and
depressed that eating may become a grave burden, that person does not sin by not eating. Clearly,
Vittoria recognizes psychic as well as physiological illness, and his notion of grave burden
involves more than physical pain.

Vittoria also discusses the morality of using artificial means, namely drugs, to prolong life:

If one has moral certitude that drugs would heal and prolong life, then one should take
the drugs himself or herself if he/she is the one sick or he/she must give them to a sick
neighbor. If he does not, he would not be excused from mortal sin. But because a cure
can seldom be certain, one need not utilize drugs even though very ill.

In considering the lawfulness of abstaining from specific foods, even if death would result,
Vittoria maintained:

It is one thing not to protect life and it is another not to destroy it. One is not held to
protect his life as much as he can. Thus one is not held to use foods which are the best or
most expensive even though those foods are the most healthful. Just as one is not held to
live in the most healthful place neither must one use the most healthful foods. If one
uses food which men commonly use and in quantity which customarily suffices for the
preservation of strength, even though one's life is shortened considerably, one would not
sin. One is not held to employ all means to conserve life but it is sufficient to employ the
means which are intended for this purpose and which are congruous3

To modern minds, Vittoria may seem liberal in the freedom he allows to refuse certain
types of food even if death will ensue more quickly. But he wrote in a time when many would do
penance by avoiding certain "more delicate" foods that might have been more healthful. For
example, members of some religious orders would never eat meat. Moreover, the underlying
reason for allowing people to abstain from healthful foods or to refrain from moving to a more
healthful place was the choice of one good (e.g., penance or family stability) that rendered the
other good onerous (e.g., eating meat or moving to the mountains). This "choice of goods" theory
is basic to the Catholic tradition on prolonging life.

Ethical Norms

Several norms set out by Vittoria are operative in Catholic teaching today:

1) A moral obligation to prolong life was assumed, but it did not hold in all circumstances.
Vittoria sought to be more specific about this obligation by asking (a) What means should be used
to prolong life when one is not ill? and (b) What means should be taken to prolong life when one
suffers from a fatal disease?

2
Relectio IX; de Temperentia.
3
Daniel Cronin, The Moral Law in Regard to Ordinary and Extraordinary Means of Conserving Life,
Gregorian, Rome, 1958.
Ethics of Prolonging Life and Euthanasia 11

2) A means to prolong life need not be used if it is ineffective, if its effect is doubtful, or if it
involves a grave burden for the person in question. To be judged effective, a medicine or
procedure had to prolong life for a "significant length of time." A means could be effective and, at
the same time, involve a grave burden to the patient--for example, eating expensive food or
moving to a more healthful climate.

3) Artificial and natural means to prolong life should be evaluated according to the same
principles: Will the means be effective, or will they cause a grave burden?

4) The burden or inconvenience involved in prolonging life includes the psychic and economic
burden as well as the physical burden.

Ordinary and Extraordinary Means

The writing of Vittoria had great influence on many theologians who lived after him. 4
However, those theologians perfected Vittoria's thoughts by considering other cases in the light of
contemporary medicine. For example, the introduction of anesthesia in the nineteenth century
caused theologians to reconsider pain as a reason for refusing surgery. However, they were not
called on to solve cases resulting from sophisticated methods of prolonging life. They did not
discuss, for example, the obligation to prolong the life of a person in a coma because no effective
means existed to do so. Therefore the distinctions of the past must often be made more exact.

The most important distinction in need of clarification is the one between the terms
"ordinary" and "extraordinary" means to prolong life. These terms were gradually introduced in
Catholic teaching over the centuries, although they were used with different meanings. 5 This led
to confusion, which was noted in the document Declaration on Euthanasia published by the
Vatican in 1980.6 The confusion arises from the fact that originally the term "ordinary" was used
in a generic sense to denote "common" means to prolong life, that is, means readily at hand and
available to all. The term "extraordinary" originally referred to means that were either expensive,
difficult to obtain, or inconvenient to arrange for the average person.

Over the years, the terms also were used in a specific ethical sense to signify whether a
particular means to prolong life was morally obligatory (ordinary) or morally optional
(extraordinary), for a particular person. Used in the generic sense, the terms signified whether the
medicine or procedure in question was readily available for the average person. Used in the
specific sense, the terms denoted whether the means to prolong life would be effective and
without grave burden for a particular person.

In theological writings, the terms "ordinary means" and "extraordinary means" were often
used interchangeably. A medicine or surgical procedure could be designated as ordinary in a
generic sense but as extraordinary when applied to a particular patient. The noted medical moral
4
The use of the terms increased in the seventeenth century. D. Banez (1604) speaks about extraordinary
means being optional. By the time of Cardinal de Lugo (1660), the terms "ordinary" and "extraordinary" are firmly in
place.
5
Congregation for the Doctrine of the Faith, "Declaration on Euthanasia," (June 26, 1980) Origins vol.10, n.
10 (August 14, 1980) p. 154-7.
6
Congregation for the Doctrine of the Faith, "Declaration on Euthanasia," (June 26,1980). Origins vol.10, n.
10 (August 14, 1980) p. 154-7.
Ethics of Prolonging Life and Euthanasia 12

theologian Rev. Gerald Kelly, SJ, used the terms in this sense as late as 1950 when discussing the
use of artificial hydration and nutrition. 7 After declaring that intravenous feeding is an "ordinary
means" to prolong life, he stated that it could be considered extraordinary for a particular patient
if he or she is not profiting spiritually from it.

Here is how we summarizes the difference between ordinary and extraordinary means:

1) Ordinary means of conserving life maybe defined as those means commonly used in give
circumstances, which this individual in his/her present physical, psychological and economic
condition can reasonably employ with definite hope of proportionate benefit.
2) Extraordinary mean of conserving life may be defined as those means not commonly used in
given circumstances, or those means in common use which this individual in his/her present
physical, psychological and economic condition cannot reasonably employ, or, if he can, will
not give him/her definite hope of proportionate benefit.

Consideration of Circumstances

Pope Pius XII solved the ambiguous use of the terms ordinary and extraordinary when he
stated that the determination of ordinary and extraordinary means requires a consideration of the
"circumstances of persons, places, times and cultures."8 In using these terms, then, one should
specify whether one is offering a general description of availability or a specific ethical judgment
based on effectiveness or grave burden for a particular patient. Simply because a procedure is
available does not imply that one has a moral obligation to use it. Respirators and blood
transfusions are readily available in all acute care hospitals, but the hospitalized person has a
choice about using them; this choice would require the patient to ask, Are these means effective?
Would their use involve a grave burden?

A more modern complication concerning the terms ordinary and extraordinary means
arises from the use of the terms in a medical context. In this context, the terms are used to
distinguish medical therapy which is standard and accepted from medical therapy which is
innovative or experimental. Thus antibiotics are ordinary therapy for pneumonia. But the
artificial heart is extraordinary therapy for degenerative heart disease. When used in this sense,
therapy which is extraordinary may become ordinary. Hence, the use of the terms ordinary and
extraordinary means to prolong life always require further specification. The terms signify
specific moral judgments only when considering the effectiveness or burden of a particular
therapy for a particular person.

Why did the theologians who developed this teaching in regard to allowing to die fail to
distinguish clearly between the generic (availability) and specific (moral obligation) use of these
terms? Perhaps they presumed that most of the means to prolong life that were effective and
readily available did not involve a grave burden for the person in question. As medical practice
and technology became more advanced, however, many available and effective means to prolong
life would result in a grave burden. For example, after the introduction of ether, amputations

7
Gerald Kelly, "The Duty to Preserve Life," Theological Studies, June 1950, p.218
8
Pope Pius XII, "Prolongation of Life," The Pope Speaks, vol.4, 1958, p.343; Congregation for the Doctrine
of Faith
Ethics of Prolonging Life and Euthanasia 13

could be performed without severe pain, but a person might determine that living without two legs
would be a grave burden and choose to live as long as possible without the amputation.

In summary, the theologians who wrote from the sixteenth to the nineteenth centuries
considered morally obligatory (ordinary in the ethical sense) those means to prolong life which
for a particular person would be effective in prolonging human life for a significant time and
would not involve a grave inconvenience. They considered optional those means which for a
particular person would be doubtfully effective for prolonging life or which would not prolong
life for a significant length of time or would be judged too burdensome.

Significant Assumptions

To understand the teaching of the theologians and later statements of the Magisterium in
regard to prolonging life and allowing to die, certain assumptions of the theologians' writings
must be considered. The theologians always assumed that suicide and euthanasia were moral
evils. Both involve a direct intention of death and action (or inaction) from which death results
directly. Clearly, the theologians did not conceive that they were fostering a direct choice of
death when they stated that life does not need to be prolonged if the means are ineffective or
involve a grave burden. Rather, they sought to allow the choice of a moral good for the person
that may also lead indirectly to death.

For example, a person who would refuse an amputation without anesthesia because it
would be too painful would be choosing to avoid excruciating suffering, even though the choice
might hasten death. To say that Catholic teaching does not allow actions that indirectly bring
about death or that may hasten death is erroneous. The theologians of the past were applying the
principle of double effect to the question of prolonging life. This principle is used extensively in
Catholic theology but is not derived from faith.9 Rather, the principle of double effect is derived
from human experience and deals with undesirable effects of human choices; effects that may be
foreseen as results of a choice but are not directly intended. If one fails to understand the principle
of double effect, one will not be able to understand the difference between the acts of suicide or
euthanasia and the act of allowing to die.

The Principle of Double Effect

The principle of double effect is brought into play whenever we are confronted by the
performance of an action which will bring about two simultaneous results or effects. One result is
perceived as good and is the one which we sincerely desire and intend to achieve, while the other
result is bad or evil and is not the object of our intention; that result is merely to be tolerated and
permitted.

The moral question that the principle of double effect wants to answer is whether or not
some contemplated action may be performed when it is clearly foreseen that some evil will result

9
Joseph Mangan, "An Historical Analysis of the Principle of Double Effect," Theological Studies, vol. 10,
1949, pp.40-61; John Connery, "Catholic Ethics: Has the Norm for Rule Making Changed?" Theological Studies,
June 1981, p.232.
Ethics of Prolonging Life and Euthanasia 14

from the posited act. This certainly will provoke doubt in the person on whether to act or not or in
what way he/she must act.

This case is typified in a woman who in her pregnancy has a malignant tumor in her uterus
whose cure will entail aborting the fetus. Moral theology will apply here the doctrine of the
principle of double effect. It is licit to execute an act which bring about two effects, one good and
the other evil provided these four conditions are met:

1. The original or proposed action is good in itself or at least morally indifferent. In the case
above the necessary surgical operation is good in itself.
2. That the motive or intention of the agent behind the performance of the original action is to
obtain the good effect and is limited in allowing the evil effect. The removal of the tumor, and
therefore the saving of the life of the mother, is the object of the operation. The risk of
abortion is something that follows or simply tolerated.
3. The primary and immediate effect must not be achieved as a result of the bad effect. In other
words, the good effect must truly be caused by the original act. Cure is the immediate result of
the operation and not of abortion.
4. There is a sufficient or proportionate reason for performing the proposed act in the first place
and thus for permitting the evil effect to occur. The proportionate reason is the urgency of the
surgical operation to save the mother’s life causing the death of the fetus through abortion in
the process.

We must remember that in dealing with a serious effect in itself, the fourth condition must
be pondered carefully. This means taking into account besides the proportionality of the reason:
the seriousness of the evil result; the immediacy of the action, the level of certainty. Likewise,
one has to underscore the obligation of preventing the damage.

The moral principle of double effect supposes a doctrinal clarity for frequent cases where
it is necessary to act, although the action is accompanied by other consequences morally evil.

Applying the principle of double effect in the case of Marcia Gray. We look at the
components of the principle.

1) The original act is to take away the nutrition and hydration. Taking away nutrition and
hydration, like an ordinary cancer operation is a morally indifferent act.
2) The intention to take away nutrition and hydration is not to cause death but to alleviate the
burden of the patient and allowing the natural process in life to take its course, hence allowing
the person to die with dignity. Death is not intended.
3) The primary and immediate effect is alleviating the burden of the comatose patient.
4) The proportionate reason is allow the person die with dignity and allow the natural
physiological process to take its natural course.

Rev. Thomas O'Donnell, SJ, indicates, when artificial nutrition and hydration are
withdrawn from a permanently comatose patient with an irreversible disease, the withdrawal of
medical care is not the cause of death. "The cause of death is the irreversible disease, which has
caused both the terminal coma and the inability to eat and drink...Thus, rather than causing death,
their withdrawal accurately could be viewed as letting inchoative death occur." 10 It seems that the
courts faced with decisions concerning the maintenance or withdrawal of life support would do
10
Thomas O'Donnell, SJ, "Comment," Medical Moral Newsletter, February 1987, p.7.
Ethics of Prolonging Life and Euthanasia 15

better to use the principle of double effect than to use ambiguous language such as "right to
privacy," "right to die," or "death with dignity."

Decisions of Conscience

The theologians developing the Catholic tradition in regard to prolonging life did not seek
to remove decisions of conscience from ailing individuals. Thus they did not compile a list of
"objective means" that were too painful, expensive, difficult, or embarrassing for everyone.
Neither did they seek to determine what would constitute "a significant length of time" to prolong
life. Rather, they determined some generic reasons that would justify the choice of a good that
indirectly led to death and called upon people to make the required specific applications. As
befits sound theology they set boundaries and allowed people freedom to make decisions within
those boundaries.

The theologians sought merely to outline general actions that people in normal
circumstances would avoid or perform to prolong life. But in regard to specific actions that might
or might not be judged ineffective or too burdensome, they called on individuals to decide for
themselves. Even eating food, as Vittoria pointed out, could be a "certain torture" for some
depressed persons, and thus it would not be a morally obligatory means of prolonging life for the
person in question. If, in some circumstances, eating food is a morally optional means to prolong
life, how much more so might be contemporary means to prolong life--ventilators, antibiotics,
blood transfusions, and artificial nutrition and hydration--be judged optional if a sick person
determines that the use of such procedures would be doubtfully effective or involve a grave
burden?

Role of the Proxy

The Church's traditional teaching then, calls on the individual to decide what is ineffective,
what constitutes "a significant time," and what is too burdensome. The theologians presumed that
if one is unable to decide for oneself, a relative or friend should decide. This is called "proxy
consent" or "substitute judgment." Persons close to the one needing help are presumed to be
moral agents for the incompetent person because they love the patient and will determine what is
of benefit to the patient. If this presumption is proven false, others, even the courts, should make
the ethical decisions for incompetent patients.

The Church's teaching does not impose on the proxy (or the courts) the incompetent
person's wishes as the absolute norm for decision making. Pope Pius XII stated: "The rights and
duties of the family depend upon the presumed will of the unconscious patient if he is of age and
sui juris [having full legal right or capacity]. Where proper and independent duty of the family is
concerned, they usually are bound only to use ordinary means."11

Thus the proxy should determine what is best for the patient, using the known wishes of
the patient as a guide, but also considering the present circumstances. An incompetent person
may have made known that a particular course of action be followed, but circumstances may have

11
Pope Pius XII.
Ethics of Prolonging Life and Euthanasia 16

so changed that the proxy believes the incompetent patient would judge differently were he or she
able to do so. For example, a person may have declared that given a certain physiological
condition or disease, that all life support should be removed. But the proxy might determine to
continue therapy in order to have the family gather before death, to alleviate pain, or to restore
consciousness for spiritual purposes. The proxy should never carry out unethical actions, for
example, acts constituting euthanasia, even if this is a known wish of the incompetent person. If
the patient's wishes are not known, the proxy should consider what would be reasonable care for
this patient. When determining "reasonableness," the proxy may ask, "How will the decision for
care affect other members of the family?" The Church's teaching on proxy consent differs from
the statements (although not always the practice) of some courts and certainly differs from the
thought of many contemporary ethicists who use the person's autonomy as the absolute criterion
for proxy decision-making. Some contemporary ethicists would approve abetting suicide or
mercy killing if it were clear this is "what the patient desired."

The Spiritual Goal of Life

Gary M. Atkinson, Ph.D., points out that Vittoria and St. Thomas Aquinas, who explained
that the moral measure of all human activity is whether it leads to God, the final end, influenced
the other theologians.12 Thus, when the theologians described something as "too difficult," they
implied that it would make loving God too difficult. The theologians did not emphasize this norm
for judging what makes a means of prolonging life "too difficult." But Pope Pius XII, in 1957,
clarified the tradition by explicitly presenting the spiritual goal of life as the norm for judging
whether a grave burden is present. He declared:

Normally [when prolonging life] one is held to use only ordinary means according to the
circumstances of persons, places, times and cultures--that is to say, means that do not
involve any grave burdens for oneself or another. A stricter obligation would be too
burdensome for most people and would render the attainment of a higher, more
important good too difficult. Life, health, all temporal activities are in fact subordinated
to spiritual ends. On the other hand, one is not forbidden to take more than the strictly
necessary steps to preserve life and health, as long as he does not fail in some more
serious duty.13

Hence any medical therapy that would make the attainment of the spiritual goal of life less
secure or seriously difficult could be judged a grave burden and could be considered an optional
or extraordinary means to prolong life.

Emphasizing the spiritual goal of human life specifies more clearly the terms "ordinary"
and "extraordinary," a specification that was not required when life support systems were not as
advanced as they are today. Contemporary life support systems may prolong a state of existence
which not only involves grave burdens for the patient, but also preclude spiritual activity on the
part of the patient. Thus a more adequate and contemporary explanation of "ordinary" means to
prolong life would be: those means which are obligatory because they enable a person to strive for
the spiritual purpose of life without grave burden. "Extraordinary" means would seem to be:
those means that are optional because they are ineffective or a grave burden in helping a person
12
Gary M. Atkinson, "Theological History of Catholic Teaching on Prolonging Life," in Donald McCarthy
and Albert Moraczewski, eds., Moral Responsibility in Prolonging Life Decision, Pope John Center, St. Louis, 1981
13
Pope Pius XII.
Ethics of Prolonging Life and Euthanasia 17

strive for the spiritual purpose of life. One cannot judge what is effective or a grave burden
without considering the physiological condition, as well as the social and spiritual circumstances
of the patient.

If it is reasonably certain that only physiological function can be prolonged in a comatose

person, and that the human organ (the cerebral cortex), which is necessary for human spiritual
activity, is unable to function, is there a moral obligation to prolong life? To pursue the spiritual
purpose of life, one needs a minimal degree of cognitive-affective function. Therefore, if this
function in an adult cannot be restored or if an infant will never develop this function, and if a
fatal disease is present, it seems the adult or infant may be allowed to die because medical therapy
is ineffective. Prolonging life simply because physiological function can be prolonged long after
cognitive-affective function ceases irreparably is not a sufficient reason to continue therapy.
Declaring medical therapy to be ineffective when spiritual function cannot be restored seems to be
the ethical responsibility of physicians.14

People may define the spiritual goal of life in different ways. The phrase "loving God and
neighbor" seems to express the Catholic tradition. Others would define the spiritual purpose of
life as serving God and neighbor, leading a good life, enjoying life, relating to others, or
contributing to society. No matter how the spiritual purpose of life is defined, some degree of
cognitive-affective function is required to strive for it. If cognitive-affective function is
irreparably lost, mere physiological function need not be prolonged because such therapy is
ineffective to achieve the spiritual purpose of life.

Comfort Care

Maintaining that the life of a fatally ill person need not be prolonged does not imply that
the person should be neglected. Every dying person should be given spiritual and physical care.
A person whose spiritual function is irreparably lost is still a human being. We have a moral
obligation to keep such patients comfortable. In regard to patients who may experience pain, the
teaching of the Church, (once again utilizing the principle of double effect) is quite clear. After
declaring that physical suffering is unavoidable and that some Christians may choose to join their
suffering with the sufferings of Christ, the Church states:

Nevertheless it would be imprudent to impose a heroic way of acting as a general rule.

On the contrary, human and Christian prudence suggest for the majority of sick people
the use of medicines capable of alleviating or suppressing pain, even though these may
cause as a secondary effect semi consciousness and reduced lucidity. As for those who
are not in a state to express themselves, one can reasonably presume that they wish to
take these painkillers, and have them administered according to the doctor's advice...In
this case, of course, death is in no way intended or sought even if the risk of it is
reasonably taken; the intention is simply to relieve pain effectively, using for this
purpose painkillers available to medicine.15

The obligation to keep patients comfortable leads some to demand artificial hydration and
nutrition for all patients in order to avoid physical suffering, even for those persons who are in an

14
E. Pellegrino and D. Thomasma, For the Patient's Good, Oxford Press, New York, 1988, p.73.
15
Congregation for the Doctrine of the Faith.
Ethics of Prolonging Life and Euthanasia 18

irreversible coma.16 But is there any medical indication that persons in this condition feel physical
pain? The neurological experts would normally not think so. 17 Moreover, in hospices and
infirmaries of religious sisters, the latter institutions being the embodiment of compassionate care
for the dying, artificial hydration and nutrition are seldom used once a dying patient lapses into a
coma. In sum, evidence seems to be lacking that removing or withholding tube feeding from
individuals in a deep coma or a persistent vegetative state results in great pain for the patient.

Burden to Others

Another latent issue in the traditional teaching of the theologians is the burden that
caregivers, usually the family, might experience if a person's life is prolonged. If all
circumstances must be considered, then the patient must ask, What will a decision to prolong my
life mean to the people who must care for me? Would the burden be in accord with "the common
sense of the Christian community" if the family would have to give the patient nursing care 24
hours a day and devote all its savings and income to that care?

Families encounter such problems often with severely debilitated newborn infants. Should
the life of every newborn infant be prolonged, simply because it can be, regardless of the burdens
this would cause the family?18 About 20 years ago Baby David was born in Houston with severe
immune deficiency (SCID). Placing him in a germ-free plastic bubble for 13 years prolonged his
life.19 Ultimately, he said it was too difficult to live in that manner and he asked that the bubble
be removed. He died shortly thereafter. The lives of other infants born with SCID could be
prolonged in the same manner, but is this humane treatment? This significant question is not, "Is
it possible to prolong life?" but rather, "Is there an ethical obligation to prolong life?"

Confirming the Traditional Teaching

In 1980 the Church magisterium, Declaration on Euthanasia spoke on the matter of

prolonging life.20 The document explains why human life is a good to be fostered and protected:

1) Human life is the basis of all human goods, and the necessary source and condition of every
human activity.
2) Human life is sacred, and no one may dispose of it at will.
3) Believers see in life something greater, name a gift of God’s love, which they are called upon
to preserve and make fruitful.

16
New Jersey Catholic Conference Brief, "Providing Food and Fluids to Severely Brain Damaged Patients,"
Origins, January 22, 1987, p.582
17
See Footnote: "Testimony of American Society of Neuro-Surgeons," p.l2.
18
While the most recent regulations from the federal government concerning cure for debilitated infants may
allow, through a generous interpretation, consideration of the burden to the parents, the first two sets of norms (which
were later declared unconstitutional by federal courts) did not allow for consideration of this burden. Clearly, the
interpretation of "grave burden" on the part of parents had led to the violation of rights on the part of some debilitated
infants such as Baby Doe in Indiana, but rights are not protected and equitably decisions are not fostered by means of
unethical laws and/or regulations. See Federal Register, May 18, 1987; Jan. 12, 1984; April 15, 1985.
19
"David the 'Bubble Boy' and the Boundaries of the Human," Journal of the American Medical Association,
Jan. 4, 1985, pp.74-76.
20
Congregation for the Doctrine of the Faith.
Ethics of Prolonging Life and Euthanasia 19

The same document also state why it is wrong to take one’s life or another’s life:

1) It opposes God’s love for that person;

2) It violates a fundamental right;
3) It is a rejection of God’s sovereignty.

The document did not change the traditional teaching in any way, but sought to clarify it
by stating:

1) The terms "ordinary" and "extraordinary" are less clear today; therefore the terms
"proportionate" and "disproportionate" means might be more accurate.

2) The patient is to make the decision concerning proper care by studying (a) the type of treatment
to be used, (b) its degree of complexity or risk, (c) its cost, (d) the possibilities of using it, and (e)
the results that can be expected, taking into account his or her condition and physical and moral
resources. If the patient cannot speak for himself or herself, the family and the physician are to
make the decision for proper care.

3) Experimental therapy even though risky may be used to obtain knowledge for the treatment of
future patients.

4) Only normal means, that is, means that do not carry a risk or a burden or are disproportionate to
the results expected, may be used to prolong life. Such a choice is not suicide but rather accepting
the human condition.

5) When death is imminent, therapy may be refused if it offers only a precarious and burdensome
prolongation of life, but at the same time, the patient should be made comfortable.

Evangelium Vitae affirms “the absolute inviolability of human life” as a moral truth
clearly taught by Sacred Scripture, upheld consistently in the tradition of the Church and
constantly proposed by the Magisterium (57). In the same number Evangelium Vitae also
declares that “the direct and voluntary killing an innocent human being is always gravely
immoral.” In this statement we can deduce that not all types of killing are a violation of the
inviolability of life and therefore immoral. Capital punishment and legitimate self-defense do not
in this category. It is only that action with a clear intention of killing on one’s own and free
initiative which is immoral. This is further qualified vis-à-vis the inviolability of life when the
person is an innocent being.
The deliberate decision to deprive an innocent human being of his life is always morally
evil and can never be licit either as an end in itself or as a means to a good end.

Killing an innocent victim is immoral because: it is a grave act disobedience to the moral
law; it is an act of disobedience to God; it contradicts the fundamental virtues of justice and
charity.

The Encyclical defines Euthanasia as “an action or omission which of itself and by
intention causes death, with the purpose of eliminating all suffering” (65). It simply follows the
Declaration on Euthanasia Iura et Bona issued by the Congregation for the Doctrine of the Faith
in 1980.
Ethics of Prolonging Life and Euthanasia 20

Evangelium Vitae distinguishes between euthanasia and the decision to forego “aggressive
medical treatment.” It defines aggressive medical treatment as

medical procedures which no longer correspond to the real situation of the patient, either
because they are by now disproportionate to any expected results or because they impose
an excessive burden on the patient and his family (65).

In this regard, forgoing an aggressive medical treatment does not constitute euthanasia or
suicide but simply an acceptance of the human condition in the face of death (65).

From this text we can deduce the following elements as components of treatment that may
be considered extraordinary: the medical procedure has no effect or benefit on the real situation of
the patient; it imposes heavy burden on the patient; it imposes heavy burden on the family; there
is disproportion to between the treatment and result that it is expected to produce or the prospects
of improvement.

Evanglium Vitae also clarifies licitness of using differing types of painkillers and sedatives
to relieve the patient’s pain but with a consequent result of shortening the life of that patient. The
licitness is traced in the teaching of Pope Pius XII. The Pope asserts that it is licit to use
painkillers if it there are no others means possible to relieve the pain and that the use of painkillers
do not impede the patient in carrying out other religious and moral duties. Patient should be given
the right to be conscious without serious reason in their preparation for their final encounter with
the Lord. The principle of double effect is applicable here since the evil effect of shortening life
is not intended but rather the alleviation of the patient’s suffering.

Although the terms "proportionate" and "disproportionate," as well as the terms "burden"
and "benefit," have replaced "ordinary" and "extraordinary" to a great extent, these more
contemporary forms are not without potential ambiguity. Before determining whether particular
substance (whether natural or artificial) or medical therapy is proportionate or disproportionate,
we must first determine the condition of the patient and whether the act or medical therapy in
question is effective in prolonging life for a significant time or whether it involves a grave burden
for a particular person.

The Patient’s Overall Condition

Joseph Sullivan noted that ordinary and extraordinary means are relative to the patient’s
condition. This is the point that must remain valid in any argument on the ordinariness and
extraordinariness of life preservation. It is the condition of the patient which:

1) sets the limits to what the available means of treatment can do and that conditions the
objective results which are possible;
2) conditions the impact which the effects of the procedure, such as pain, will have on the person;
3) conditions the subjective response of the person.

According to Joseph Sullivan “a natural means of prolonging life is per se an ordinary

means of prolonging life yet per accidens it may be extraordinary,” and “an artificial means of
prolonging life may be an ordinary or an extraordinary means relative to the physical condition of
Ethics of Prolonging Life and Euthanasia 21

the patient.” What Sullivan is actually saying is that it is irrelevant whether the means of
treatment are natural or artificial. What counts for a moral judgment is whether or not the means
can bring benefit to the patient, and whether the means causes burden to the patient or not. In
other words, we have to take into consideration not only the patient’s condition in relation to a
particular disease and the means available to treat it, but also the total condition of the patient.

For example, a patient has diabetes. Under normal circumstances insulin treatment would
be ordinary. The judgment is made on the grounds that the insulin treatment can provide real
benefit to the patient in controlling diabetes, and that it does not place undue burden on the
patient. If the patient also has terminal cancer, this would affect the total condition of the patient.
We could control the diabetes, but could not cure cancer. Therefore we cannot cure the total
person. In this case we are not obliged to use insulin because we could consider it as an
extraordinary means on the grounds that while it can control a particular disease, it cannot cure
the person’s total condition.

Care must be taken in applying the total condition of the person principle. For example,
some infants are born with blocked esophagus. This condition can be corrected by surgical
intervention with a secure prospect of success and without causing undue suffering to the infant.
This intervention is considered ordinary means of treatment. But if the infant with a blocked
esophagus is also afflicted with Down’s syndrome. Could be argued that the means of treatment
becomes extraordinary?

We cannot apply here the principle of the total condition of the patient like what we did in
the first case. Therefore we cannot consider extraordinary, the operation to unblock the
esophagus because the condition of Down’s syndrome does not impede the effectiveness of the
surgery in correcting the blocked esophagus. Down’s syndrome is likewise not morally
equivalent to such a condition as terminal cancer. To treat the person for diabetes while in state of
terminal cancer merely puts back the person in the same terminal state. On the other hand,
correcting a blocked esophagus enables the child to live, even though it will have more limitations
that a normal child. The incurable condition of Down’s syndrome in no way makes the treatment
extraordinary.

If these basic moral specifications are not discerned, then a consequentialist's

interpretation could result from use of the new terms.

Norms Governing the Decision

In summary, then, these are the important norms in regard to prolonging life gathered from
the theologians and the magisterium:

1) Because human life is a great good, a presumption exists that human life should be prolonged.
However, this presumption ceases if the means to prolong life are ineffective or involve a grave
burden for a particular person.

2) The spiritual goal of life indicates when life-prolonging efforts become "ineffective" and
enables one to measure grave burden.
Ethics of Prolonging Life and Euthanasia 22

3) No list of human actions or medical procedures can be determined as ordinary or extraordinary

from a specific ethical perspective. A general description of means that are usually available,
often prolong life, or seldom involve a grave burden is possible, but specific ethical judgments
require a consideration of all circumstances. Therefore one must specify whether the terms
"ordinary" or "extraordinary" are being used in a general or specific sense.

4) When determining the moral obligation of whether to prolong life, we must know the patient's
diagnosis and prognosis, as well as the "circumstances or persons, places, times and cultures."
Only then may one determine what is morally obligatory and what is optional.

5) If possible, the patient should be allowed to make decisions for himself or herself. If the patient
is clearly not competent, however, a proxy is called. The proxy determines what is beneficial for
the patient, taking into consideration all circumstances that a reasonable person would have
considered, including the burdens on the family.

6) The decision to choose a good that entails discontinuing the use of a life support system may
hasten death. But death is the indirect result and occurs because one chooses another legitimate
good.

Quality of Life

There are three levels how the notion of quality of life functions in moral arguments:

1) Descriptive level. The first level entails identifying certain functions or capacities of living
human, e.g. vital and metabolic functioning, sentience, consciousness, desire, relating to
others, etc.
2) Value judgment level. The second level calls for value judgments on these functions and
capacities. This means that these functions and capacities are assessed as goods or values. A
typical quality of life argument would judge that a life that included vital and metabolic
functions, consciousness, desire and capacity to relate to others was more of a value than a life
which included only vital and metabolic functions.
3) Normative judgment level. On the third level normative judgments are made. This is
expressed by judging that this life has such a low quality and therefore so love a value.
Because of this it is not meaningful, not worth living or not worth saving. From this judgment
comes the normative—such life must not be sustained or it may be directly taken.

This is the characteristic structure of the quality of life argument. Some the arguments
against the quality of life principle are the following:

1) It rejects the equality of human lives and so the equality of human persons. There are two
arguments to sustain this position:

a) The first argues that because the quality of life proponents uphold that a certain life lacks
certain qualities, it is therefore of deficient value to society. To concretize this, let us say
that an infant is born with a severe physiological damage, on the grounds of deficient
quality of life a judgment is made that it does not merit the care given to normal persons in
society. Therefore, if we follow this argument, one life is more valuable than the other.
Furthermore, the judgment is made based on the criteria others have chosen and which are
assessed according to criteria they have likewise chosen. This is clearly a form of
discrimination on several counts.
Ethics of Prolonging Life and Euthanasia 23

b) The second type of argument would propose that a person might lack so many of the
qualitative aspects of life (e.g., capacity to relate to others) and because of this that life is
of little value or no value at all to that person. Unlike the first argument, this one does not
make judgments of social value and therefore seems to be acceptable. However there are
at least two difficulties we find in this argument: (1) who is to judge that this kind of life is
of no value to the person concerned and (2) and on the basis of what criteria is that
judgment to be made? These difficulties arise in a number of cases but more especially in
severely damaged infants. Is it possible that another person make some kind of substituted
judgment for the infant, that the kind of life possible to him/her is of no or little value? It
is also possible that the person him/herself makes the judgment. Here we do not have the
problem of someone making a judgment over one’s life but person him/herself makes the
judgment that “This life is of not value to me.” While there is a difference here in the
person making the judgment, we still have difficulties.

2) Life is constitutively good. It is good to be alive not only because life enables one to do other
things, but also because life itself is good. This means that while life is not a supreme or
highest good, it is a constitutive good of the human well-being. The quality of life will
consider life as an instrumental good and therefore if life is not instrumental to the good of
society it is not worth keeping anymore. If life is a constitutive good, to choose directly
against the good of life is morally wrong. Therefore, directly taking of life is wrong
independently of the argument from the dominion/stewardship principle. To express this
normatively we say that a person may not judge that his/her life is of no value (i.e., good to
him/her). Life is necessarily good because it is a constituent element of the human good.

3) The sanctity of life as another form of argument from lack of dominion may also be used
besides arguments of the equality of all human lives and the constitutive goodness of human
life.

Public Policy and Ethics

Although the ethics of personal decision-making that will ensure the fulfillment of our
response to God's love is a serious concern of the Church, the Church is also concerned with
public policy in regard to prolonging life. Laws and court decisions are an important adjunct to
personal decision making because they serve as an educational as well as a coercive factor in the
lives of individuals.

When offering prudential advice to the courts and legislatures in regard to public policy,
however, the statement of Church agencies should be in accord with the traditional teaching of the
Church. The National Conference of Catholic Bishops Committee offered a good example of
accurate advice for Pro-Life Activities. In commenting on the statement on Uniform Rights of the
Terminally Ill Act proposed by the Commission on Uniform State Laws, the bishops cautioned
against promoting euthanasia and requested that legislation establish a strong presumption in
favor of using artificial nutrition and hydration. But the statement also allowed for withdrawal of
life support that is ineffective or a grave burden and agreed that "laws dealing with medical
treatment may have to take account of exceptional circumstances when even means for providing
nourishment may become too ineffective or burdensome to be obligatory."21

21
"Statement on Uniform Rights of the Terminally Ill Act," Origins, June 26, 1986, p.222.
Ethics of Prolonging Life and Euthanasia 24

Contrasted with the Pro-Life Committee's statement is the statement of the New Jersey
State Catholic Conference in regard to the Jobes case. Nancy Ellen Jobes, 31 years old, was
severely brain damaged and her existence was maintained by means of artificial nutrition and
hydration in a nursing home. Her spouse asked the court for permission to withdraw all life
support systems. After maintaining that Nancy Jobes "is not dying," the amicus curiae brief of the
New Jersey Catholic Conference stated: "The conference maintains that nutrition and hydration,
being basic to human life, are aspects of normal care, which are not excessively burdensome, and
should always be provided to a patient." 22 In June 1987, the New Jersey Supreme Court granted
permission for the withdrawal of all life support systems from Mrs. Jobes stating that the right of
a patient to refuse life-sustaining medical treatment may be exercised by the patient's family or
close friend. Thus the court held that in certain circumstances withdrawal of nutrition and
hydration is neither euthanasia nor suicide.

Although the intent of the New Jersey Catholic Conference to avoid "a slippery slope" in
matters of allowing to die is laudable, accurate ethical distinction must be used or the Church
teaching in the matter, which has been respected and followed by many in our pluralistic society,
will lose credibility.

Conclusion

Understanding and following the Church teaching in regard to life support will not make
the decision to withhold or withdraw medical therapy an easy one. Such decisions will always be
accompanied by anxiety and sorrow. Decisions of proper ethical care will continue to bother and
befuddle healthcare professionals, patients, and their families. Indeed, the degree of anxiety and
sorrow accompanying these decisions may be a good measure of one's humanity. However, the
Church teaching will enable people to make just and compassionate decisions that express
effectively their love for God. The papal magisterium in the latest statement in this regard sums
up the issue well:
"Life is a gift of God, and on the other hand death is unavoidable…Death marks the end of
our earthly existing but at the same time it opens the door to immortal life. Therefore, all must
prepare themselves for the event in the light of human values, and Christians even more so in the
light of faith."23

22
New Jersey Catholic Conference Brief.
23
Congregation for the Doctrine of the Faith. The Catholic Health Association of the United Stales is the
national organization of Catholic hospitals and long term care facilities, their sponsoring organizations and systems,
and other health and related agencies and services operated as Catholic. It is an ecclesial community participating in
the mission of the Catholic Church through its members' ministry of healing. CHA witnesses this ministry by
providing leadership both within the Church and within the broader society and through its programs of education,
facilitation, and advocacy.