I wanted to tie up something that I meant to blog about during the Terri Schiavo crisis, though events overtook me and I wasn’t able to do so.
During the crisis, I received several requests from folks for comment about why food and water were considered "ordinary" means of sustaining life, regardless of their method of delivery, whereas going on a respirator was considered "extraordinary" means.
It’s a good question. Food, water, and oxygen are all essential material requirements for the typical care of the body. If the first two must be delivered regardless of the means of delivery, why not the third?
This is an area where the advent of new medical technologies has had a significant impact, and the Church is still sorting these matters out, but let me offer you what I can on this.
There is a development in the terminology of moral theology that seems to be happening at present. The older terminology divides life-saving measures into "ordinary" and "extraordinary" means, whereas the newer terminology divides them into "proportionate" and "disproportionate" means. Currently the Magisterium is using both sets of terms, but there is a shift that seems to be occurring from the former to the latter. In the future, the former terminology may be replaced by the latter or the former may be interpreted so that it means the same thing as the latter. We’ll have to wait and see.
In any event, the old distinction between "ordinary/extraordinary" is undergoing significant change because the advent of technology has made many things that would have formerly been quite extraordinary before the 20th century to be quite ordinary in the 21st. What was considered an ordinary thing to do for a sick person was much the same in the 10th century as it was in the 15th, but would bear very little resemblance to what would be an ordinary thing to do for a sick person today.
The shift in terminology is reflected, for example, in the Holy See’s 1980 Declaration on Euthanasia, which says in part:
Those whose task it is to care for the sick must do so conscientiously and administer the remedies that seem necessary or useful. However, is it necessary in all circumstances to have recourse to all possible remedies? In the past, moralists replied that one is never obliged to use "extraordinary" means. This reply, which as a principle still holds good, is perhaps less clear today, by reason of the imprecision of the term and the rapid progress made in the treatment of sickness. Thus some people prefer to speak of "proportionate" and "disproportionate" means. In any case, it will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources [SOURCE].
The Holy See thus notes that the term "extraordinary means" is problematic because it is imprecise and subject to rapid technological progress. While acknowledging that the term can still be used in principle, it offers a series of considerations for determining whether a treatment should be used that converge on what is captured by the terms "proprotionate" and "disproportionate"–i.e., the complexity and risk of the treatment, the cost and possibility of using it, the result that can be expected, the state of the sick person and his resources, etc.
In the absence of a Magisterial clarification of the meaning of the ordinary-extraordinary distinction that sets it on a firmer footing, I’m inclined to say that the proportionate-disproportionate distinction better captures what Catholic moral theology requires–and what older moral theologians were after when they used the terms "ordinary" and "extraordinary."
It seems to me that when they referred to "ordinary" means of saving someone’s life, they meant things that had reasonable prospects of helping, did not significantly burden the patient, did not put him at great risk, and were not extremely difficult to pursue. By contrast, if something had low prospects of helping, greatly burdened the patient, put him at great risk, or was extremely difficult to pursue then they regarded it as an "extraordinary" thing to do.
Today, because advancing medical technology is rapidly shifting things from the "extraordinary" column to the "ordinary" column, it seems to me that "proportionate" and "disproportionate" express the same distinction in a less confusing way.
At least most of the time.
‘Cause there’s a big disclaimer that needs to be mentioned.
Whenever you get the word "proportionate" into a moral discussion, certain individuals will self-righteously sniff and say "That’s just proportionalism."
Wrong.
The idea of proportion is something that involves weighing the costs and risks of an action against the benefits to be obtained by pursuing it. That’s not at all alien to Christian moral theology. Indeed, both Testaments of the Bible contain material that is based on this kind of prudential judgment.
What proportional-ism does it is takes the idea of proportion and absolutizes it, making it the only criteria that is relevant. It allows any action to be undertaken as long as the benefits it stands to result in are considered proportional to its costs and risks under an immediate, this-worldly calculus. That’s why proportional-ism is condemned. But the use of the idea of proportion in making a moral judgment is not. In fact, in many situations it is required–failing to make use of it being a sin against the virtue of prudence.
So I don’t want to hear a lot of "You’re just talking about proportionalism" stuff in the combox, because I’m not. Self-righteous sniffers take warning.
Having said that, let’s apply these principles to the situations of artificially providing food, water, and oxygen.
It seems to me that in principle they are all the same: They all are things the body needs to survive and their administration thus does not count as medical treatment. The default position on all three is that, unless something else is affecting the situation, their administration is proportionate and morally obligatory.
However, in various situations all three of the administration of all three can become disproportionate and thus non-obligatory.
We have already discussed, for example, the case of an individual whose body has stopped manufacturing albumin. In such a situation, continuing to administer food and water intravenously will result in horrible damage being done to the body and thus is not morally required. In that case the administration of food and water has become disproportionate to the good to be achieved and it is no longer obligatory.
If it’s merely a matter of putting a food and water tube in someone’s mouth or nose or stomach and the person is otherwise able to process food and water then the adminsitration of them will be proportionate (unless something else is affecting the situation), but in the case of someone who can’t manufacture albumin, even a simple food and water tube becomes disproportionate because his body is no longer able to process fluids and he will be positively harmed by pumping them into the patient.
When it comes to oxygen, if it is merely a matter of attaching an oxygen tube to someone’s nose so they can breathe, again this is a simple enough thing that it’s going to be proportionate (unless something else is affecting the situation) and thus morally obligatory.
But if we’re talking about someone who needs an iron lung (a very small class of people today) then we’re talking about a much more burdensome and costly procedure that can more quickly become disproportionate.
That’s the difference. While food, water, and oxygen are all are all necessary substances for the body and while their artificial administration is presumed to be proportionate until proven otherwise, certain means of delivering them become disproportionate or "extraordinary" more quickly because technology has not yet been developed that renders them non-burdensome.
In the case of food and water, we have means that are fairly non-burdensome unless there is something wrong with the patient’s ability to assimilate food and water. In the case of oxygen we may be improving on this point, but at least certain oxygen-delivering technologies are still more burdensome and thus fall into the disproportionate or "extraordinary" category more easily.
When something falls into the disproportionate or "extraordinary" category, one can morally choose not to use it even though death will inevitably result. One cannot, however, discontinue proportionate or "ordinary" means in order to cause death, neither may one deliberately undertake any other course of action that, as a means or as an end, is intended to kill the patient.
No matter what advocates of proportionalism would say.
Mr. Akin – Thank you for posting this. It’s something of a tricky subject, with shifting definintions, as you point out, but you’re the only one I know of who has even attempted to clarify this point. Much appreciated.
Dr. William May and others have summarized the proprotionality analysis as assessing the degree of burden and usefulness of a given treatment. Here are few other factors I think are relevant to proportionality of administering air/oxygen.
First, and you address this, artificial administration of air through a tube in the face might be more uncomfortable than administration of food and water by a tube through the abdomen. Second, and a doctor could address this one much better, if air is not being brought in or processed sufficiently, this seems to point to a more serious health problem than the inability to take in food and water, and the lack of air leads to death more quickly than the lack of food and water. Third, food and water are normally delivered into the body from the outside, by one’s own or another’s hands. Air, however, is sucked into the body from the inside by breathing. If someone is unable to suck air onto his own body, this seems to be a different kind of problem than the inability to take in food and water.
I would say that the difference is that out of the three, oxygen is already present for the patient. One does not consume oxygen like food and water. The body naturally and automatically processes it. Both food and water can be denied, but oxygen cannot unless one purposefully suffocates someone.
Therefore, if one is sick and too weak to feed themselves, in the past others have taken it upon themselves to feed them. But if one’s body fails to the point they can’t process oxygen, there is nothing anyone can do. Because of that, artificial attempts to do that is invasive and therefore extraordinary.
GenXsurvivor – Can you provide a reference for Dr. May’s analysis (either in print or online)? Thanks.
“But if we’re talking about someone who needs an iron lung (a very small class of people today) then we’re talking about a much more burdensome and costly procedure that can more quickly become disproportionate.”
What burden is there to the patient other than the cost and the need to remain in the hospital? And if that is the only additional burden, and it is enough of a burden to make the delivery of oxygen (by certain means) disproportionate, how do we analyze the other aspects of caring for a person who is in a coma or persistent vegetative state and unable to take food and water through normal means? The feeding tube has to be cleaned periodically, the patient has to be turned and provided with physical movement (to prevent bed sores), arrangements need to be made to remove bodily wastes, infections are common and will require anti-biotic treatment, the list is quite long. Typically, patients in this situation require round-the-clock nursing care and confinement in at least a skilled nursing facility in addition to nutrition and hydration. Do those other services add up to “disproportionate” means? If not, then how are they less “disproportionate” than the use of a respirator or iron lung? Won’t it all depend on exactly which services the patient requires and how much they cost?
Receiving oxygen through a tube is one thing, a ventilator (which essentially breathes for you) is another.
If my brain has been damaged to the point that it can’t control organ function, I would wish to have them “pull the plug”. If, on the other hand, I simply need a little oxygen, hey… don’t get stingy.
But what makes the ventilator “disproportionate” while the oxgen tube is “proportionate”? Neither is very uncomfortable for the patient. Both may be essential to keeping the patient alive. Neither is risky to the patient or involves side effects. Neither is invasive. Isn’t the difference just that the ventilator (along with the required ancillary medical services) involves a higher level of care and is therefore more expensive? And if that is the difference, then what about long-term care in a skilled nursing facility (including regular physical therapy, personal hygiene, turning and massaging, antibiotic treatment, etc.) for a bed-ridden person with no prospects of improvement? It’s not like you just put in the feeding tube and then leave the patient alone. They need a lot of care in addition to the feeding tube or they’re going to get sick and die of something else.
I would beg to differ on the point of the ventilator not being comfortable. I have never been on one myself, but my father was on one twice prior to his final, fatal stint on it. He had made it quite clear to us all that he didn’t want to stay on a ventilator indefinitely. It ended up not being a real question because all his organs began to fail pretty much simultaneously. Before it became clear, though, that he was not going to recover from his final bout, I found him doing something rather amazing in the ICU. Most the time, it was clear from the monitors, the ventilator was doing nearly all the breathing “work” for him. However, whenever a nurse came in to check on him, he would exert himself and try to carry more of the “work” load himself– apparently trying to demonstrate to the nurses that he really didn’t need to be on the ventilator… As soon as the nurse would leave, though, he would have to stop working at it because it was just too difficult to keep up.
That is interesting input. But, I’m sure a lot of people wouldn’t want to be on a feeding tube indefinitely either. That desire may or may not be based on a factor that makes the treatment “disproportionate.” Did your father ever indicate that the ventilator itself caused him signficant discomfort and pain, or was it just a more general displeasure with being in such a compromised state and a sense that “if this is what it takes to keep me alive, then I’m ready to let go”?
It becomes simpler if you put it this way:
Extraordinary measures are not required if a patient has a terminal illness and his or her outcome would be death, regardless.
Terri Schiavo and those with varying degrees of brain damage like her are not terminally ill. Fatal brain *cancer*, or any other terminal illness, would be a different story. Comfort is the main consideration in determining whether a patient or his or her guardian can refuse food and water when the outcome will be death regardless.
People cannot look at a brain damaged person and consider them to be the same as a terminally ill person. For one, there are many different degrees of brain damage. Secondly, the temptation to do this comes from projecting our own biases of what’s valuable about that patient’s life. (“But she can’t do the kinds of things I can do!” is basically what they say. That’s not how we judge others’ right to live.)
In contrast to a terminally ill person, a brain-damaged person can live a full lifespan with the same requirements as anyone else – in Terri Schiavo’s case we specifically mean food and water. We were simply providing her with that, albeit artificially, but it’s not as though we were also artificially digesting it for her as well. (If that were the case with someone, it would most probably be because they had a terminal illness, right?)
In the case of iron lungs and such, think about what is probably wrong with a person that necessitates that they be in an iron lung. They are likely _terminally_ill (lung cancer, emphysema, etc.).
If it’s a matter of a serious injury (such as from a car accident), then an iron lung, if it even could be used on such an injured person, would be a temporary means to keep someone alive until recovery, assuming that there is in fact a hope of recovery. In contrast, in cases of terminal illness, though, death would be the outcome regardless and it would not be required. Attempts to prolong a life, especially if much suffering is involved, would be disproportionate, unnecessary, and … “extraordinary”.
Okay so not many people on iron lungs have lung cancer or emphysema but you get my drift. 😉 I just slapped my forehead after I typed that and realize I can’t edit it. However, the inability to respire likely still lies in having a fatal illness or very serious injury, the latter of which may or may not lend any hope of recovery. Hope of recovery is then what would be considered. Outside of hope for recovery, when death is inevitable regardless, one would then consider what is “proportionate”, which includes many things such as whether suffering is actually being alleviated and so forth and so on.
I have a Q after how many days do you expect a normal human being to die by starvation with out any disease?
It depends on how good a health the person is in at the time starvation begins. It also depend on whether the person receives water during the starvation.
If a person has no food but does have water he may be able to survive as long as 40 days.
If a person has neither food nor water, he may be able to survive a week to to ten days if memory serves.
That’s assuming that the person is in good health. Individuals in poor health would survive less long.
HERE’S AN ARTICLE FROM SCIENTIFIC AMERICAN ON THE SUBJECT.