Taking Your Heart Medicine

A reader writes:

Jimmy (may I presume to use your first name? If not, Mr. Akin):

I love listening to you on Catholic Answers — as they say in talk radio, I’m a long time listener, first time talker. Anyhow, your excellent discussion of the stem cell issue leads me to ask a different question on Catholic medical ethics:

Ken Lay died of a heart attack recently. If he had stopped taking heart medicine, thus hastening his death, would that be suicide? To what extent is someone required to take life-saving medicine?

The Catechism does not seem to contain a technical definition of suicide, so I’m going to have to fall back on my own understanding of the term, which is that suicide is undertaking a course of action in order to bring about one’s own death.

By undertaking a course of action, this doesn’t have to mean taking positive action, like putting a gun to one’s head or injecting a toxic drug into your body. It can also be refusing to do those things that would reasonably be expected of a person in an effort to preserve his life.

For example, if you found yourself in the middle of a busy street with a bus bearing down on you and you refused to step out of the way so that you could get run over and die then I would say that was suicide even though the "action" you performed was a refusal to do something (i.e., step out of the path of the bus).

For someone taking heart medicine (and I notice that you didn’t say Ken Lay was or that he discontinued taking it, you just used him as a hypothetical example), a refusal to take the medicine would seem to count as suicide if two conditions were fulfilled:

1) The person discontinued the medication in order to bring about their death, and
2) The personal was morally obligated to take the medication.

A person could discontinue taking the medicine without fulfilling condition (1) if there was some other reason for the discontinuation. For example, the person may have run out of the medicine and didn’t have the money to buy more and couldn’t find a source that would donate it to him. (This might be the case for many people with heart problems in the third world, for example.) It might also be that the heart medicine was causing horrible side effects (let’s say he developed a severe allergy to it) and the motive was to stop the allergic reactions rather than to bring about his own death. He might also have joined a religion that forbids the use of medicine.

If his motive was something other than bringing about his own death then I wouldn’t be inclined to call it suicide. I think that the intention to kill oneself is an indispensible part of suicide in the proper sense. It’s that intention that distinguishes suicide, for example, from recklessly endangering one’s life (i.e., taking unacceptable risks with it in the absence of the intention to kill oneself).

Note that the motive might or might not be a good one. If he has a good reason for discontinuing the medication (like, he simply can’t get any more) then if he dies as a result of not taking it then he has no moral culpability in his death. On the other hand, he might have a bad motive (like he just doesn’t like the color of the pills). In the latter case he would bear moral culpability for his death, though the sin would not be suicide in the proper sense since there was not an intent to bring about his own death (the intent being not to take pills of that color).

All this deals with the first condition necessary for suicide. Now let’s look at the second:

What medical treatments are morally obligatory? Historically, this question has been answered in terms of "extraordinary" vs. "ordinary" treatments. Those treatments that were ordinary were ones that a person was morally expected to perform, whlie extraordinary ones were not morally obligatory.

This distinction worked well in the 1500s, when medicine wasn’t changing very fast. People had an intuitive sense of what procedures were ordinary vs. extraordinary, but with the massive change in medical technology that we are currently in the middle of, treatments that were once not just extraordinary but impossible are now totally ordinary (e.g., taking your insulin if you’re a Type 1 diabetic).

Consequently, Catholic moral theology has been reframing the discussion not in terms of what is ordinary vs. extraordinary but what is proportionate vs. disproportionate. The Holy See’s 1980 Declaration on Euthanasia takes note of this:

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.

The distinction between what is proportionate and what is disproportionate is dealt with by what the declaration goes on to say:

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.

In other words, there is a cost:benefit analysis that needs to be performed, comparing the costs (pain, discomfort, side-effects, money) to the benefits he will receive. If the benefits clearly outweigh the costs then the procedure is proportionate to the problem it is trying to address. On the other hand, if the costs clearly outweigh the benefits then the procedure is disproportionate.

Now, whenever the word "proportionate" gets involved in a moral discussion, some folks are inclined to start lobbing accusations of "proportionalism," so I need to issue

THE BIG RED DISCLAIMER: What I am talking about here is not proportionalism. Proportionalism is a system of thought that makes the proportions of costs and benefits the ONLY criteria to be taken into account in a moral appraisal. That’s why it’s got the -ism tacked on to the end of "proportional," because it makes proportionality the be-all and end-all of moral theology.

Under proportionalism one could not only forego treatment if the costs outweighed the benefits, one could positively kill the patient–put a gun to his head and pull the trigger–if it were deemed that the benefits of doing so (ending suffering) were greater than the costs (one bullet).

Proportionalism is a false moral system, but not all discussion of proportionality means that someone is advocating proportionalism. Orthodox Catholic moral theologians discussion proportionality all the time. It’s just when it gets made into the exclusive criteria of morality that we have proportionalism.

And the Holy See is not averse to taking the proportionality of the costs to the benefits into account, as see from the quotation above and from what the Declaration on Euthanasia goes on to say:

It is also permitted, with the patient’s consent, to interrupt these [advanced or even experimental] means, where the results fall short of expectations. But for such a decision to be made, account will have to be taken of the reasonable wishes of the patient and the patient’s family, as also of the advice of the doctors who are specially competent in the matter. The latter may in particular judge that the investment in instruments and personnel is disproportionate to the results foreseen; they may also judge that the techniques applied impose on the patient strain or suffering out of proportion with the benefits which he or she may gain from such techniques.

The document also says:

Therefore one cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community.

When inevitable death is imminent in spite of the means used, it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted. In such circumstances the doctor has no reason to reproach himself with failing to help the person in danger.

So: It seems to me that whether a refusal to take one’s heart medicine is suicide will depend (1) on whether the persons is discontinuing it precisely in order to cause his death and (2) whether the use of the heart medicine is proportionate to the benefits it will give the patient.

If a person can reasonably afford the heart medicine and it is expected to keep him alive without causing horrible suffering then it seems to me that the use of the medicine is proportionate to the benefit to be achieved and thus he is morally obliged to take it.

If he refuses to take it in order to kill himself then it’s suicide. If he refuses to take it for some other inadequate reason then it is something else, such as reckless endangerment of his life.

Hope this helps!