Catholic teaching provides a balanced view that rejects
euthanasia while accepting
the morality of refusing burdensome treatments.

The Morality of Refusing Medical Treatments

By John Balluff

NOTE: This first appeared in the July 2004 issue of HPR

There is currently a war of cultures in our country whose opposing camps have been accurately named by our Holy Father as the “culture of death” and the “gospel of life.” In the culture of death, death is seen as an answer to challenging human situations such as living with pain or disabilities. In this article we want to both affirm the clear teaching of the Catholic Church on the immorality of any activity that directly and intentionally kills a patient and at the same time to focus on another aspect of Catholic teaching as regards the morality of refusing medical treatment. In our polemic against euthanasia we must be careful not to over simplify the Catholic position when it comes to the obligation of society, the individual, or the family to provide expensive or painful medical treatments that may extend the life of the individual. Death itself is not an answer to the difficulties of life but neither is it the ultimate enemy. It is a necessary part of our journey to God, not to be avoided at all costs but accepted when the time comes.

There will be situations in which an individual or those who have the right to speak for the incapacitated individual can morally refuse medical treatments. To understand how the above choice can at times be a moral one we have to recall both the physical and spiritual nature of the human being. The basic recipe of a human being includes the body and the soul. Every individual is the result both of a biological conception, wherein the parents cooperate, and the infusion of the soul, wherein God participates in an immediate way by the creation of the individual soul. The human person naturally has an earthly life and an eternal destiny. That eternal destiny is also potentially a heavenly destiny because of the redemption.

What happens and what decisions are made during this earthly pilgrimage cannot be conceived of in the narrow perspective of the here and now. The only reasonable basis on which to make decisions must include our eternity. This very obvious point is frequently denied a hearing because what is reasonable is understood in terms of what is commonly held verses what is true in itself. Frank Sheed wrote a wonderful book entitled Theology and Sanity in which he says “Sanity, remember, does not mean living in the same world as everyone else; it means living in the real world.”

When we define the human being as body and soul we are accepting that this perspective tells us something of the real world even if this perspective is not the majority point of view. Too frequently we abandon reason and try to confront the culture of death on its own terms, a deformed understanding of human nature. We do not have to surrender the terms of the argument, i.e., the basic definition of what a human being is. If we avoid the discussion of human nature then our arguments against euthanasia or our understanding of when it is legitimate to refuse medical treatment will have a weak foundation. We end up being doctrinaire and beating others over the head with our teachings without being able to actually show them the truth of the teaching. Without understanding how the life of the soul is important in deciding about the life of the body the Catholic position, which rejects euthanasia but does not always require that we accept or provide medical treatment, will seem arbitrary.

The spiritual and the material reality of the individual will sometimes mean that certain medical procedures which could benefit the body of the person may not be the best thing for the individual involved. This scenario is true whether the individual is making health decisions for himself or has reached a state of dependency where his family members must decide for him.

The health of the body must not be considered apart from the health of the soul. If the body was the only determining factor in making medical choices or for that matter the only determining factor in daily or vocational choices then probably a great number of virtuous activities would never be considered. Fasting, the long hours of prayer in the contemplative life, missionary activity in dangerous lands, parenthood, and the vocations of countless saintly people would never be considered. Father Damien of Molokai, and many others, made decisions that put their bodily health at risk but led them and others to great sanctity or health of soul.

It is obvious that there will be many occasions when the health of the body conflicts with the health of the soul. This lack of harmony or integration between the health of the body and the health of the soul is the sad result of living in a world disintegrated by original sin. Jesus will himself become a victim of the sometimes-violent conflict between virtue and bodily health. When he decides to go to Jerusalem for the last time he recognizes that the journey will certainly lead to his death (Matt 20:17-19). His choice is replayed throughout the history of the Church and continues to be the experience of contemporary martyrs.

What we have said so far should not be taken as a denigration of the body. We have spoken rather of the context of bodily health. Nothing really is asked of the body that has not already been asked of the soul. Bodily death is a necessary prelude to the resurrection. But even in this life the body is only following the example of the soul which has already experienced a kind of death. “Do you not know that all of us who have been baptized into Christ Jesus were baptized into his death?” (Romans 6)

The discussion above has so far focused on the vitality of the soul and its health by way of the example of the saints. Suffering is not meaningless but can in fact be very important in the scheme of things. However, it is very important to understand that while the Church would rejoice if all its sons and daughters possessed the heroic virtue of the saints and were able to embrace great suffering joyfully with merit for themselves and for others, the Church, as a loving mother knows this is not the case. The Church is a mix of saints, some real sinners, and the great muddling masses. The Church loves the mediocre among her children and does not require or demand a heroism of which they are not willing or capable.

We are obligated to avoid mortal sin but we are not obligated to practice heroic virtue. Even though it is a praiseworthy thing to give all you have and serve the poor it is not an obligation. Even though it would be a good thing to fast every Friday for peace it is not the norm. It would be wonderful if all Catholics gave away their supply of aspirins and offered up their headaches for more vocations, but none are required to do so. While some of these greater or lesser sacrifices, if lived out, would lead to great spiritual benefit it is also true that if some Christians took on sacrifices of which they are not capable the results could be tragic, leading to apostasy.

Humility is in part accepting the ordinary type of sanctity that providence determines for us. It is better to accept our own weakness with humility than venture forth in a task, which we cannot complete. God not only provides grace but he also provides the human qualities, perhaps not yet exercised, that we will need to do his will. If we simply are not capable of something, in a sense, this is an expression of God’s will.

Discerning God’s will, expressed by the desire of an individual seminarian and novice and by their native capacities, is a necessary part of the evaluation of candidates. To invite people into a life for which they lack the capacity is to invite them to failure and potentially grave sin. Whereas if individuals follow a vocation more in line with the gifts that God has given them, they will live less inspiring but more secure lives avoiding more serious sins.

It is not unusual in the medical field to encounter procedures that will save the patient’s life but leave him so handicapped or in constant pain that to simply avoid cursing God requires heroic sanctity of the individual. Some years ago I offered Mass in the apartment of a man totally paralyzed. The congregation was made up of his caregiver and Mother Teresa’s sisters. At the end of the Mass the gentleman asked for prayers because he lived with the temptation of despair and keeping his faith was a daily battle. This particular gentleman was a great inspiration but also lived in constant spiritual danger. Imagine yourself in such a state, being kept alive and basically comfortable but totally without movement. In such cloistered circumstances a soul could become very saintly or very bitter and despair. The experience could be purgative or a premature hell.

After the fact the individual has to deal with his circumstances with the grace of God. But before the treatment he has the right to refuse a cure that may keep him alive but lead to such a state that his soul might despair. Here the individual must consider the health of his body in the context of the health of his soul. We are not obligated to give the health of our body or life in this world such a value as to endanger our life in the next.

To forgo extraordinary or disproportionate means is not the equivalent of suicide or euthanasia; it rather expresses acceptance of the human condition in the face of death. (Pope John Paul II, Gospel of Life #65)

We can accept that human suffering has meaning without necessarily consenting too quickly to put one another through it. We should not accept it imprudently for ourselves even if it keeps us alive in the body. We are not obligated to accept every treatment for ourselves nor are we obligated to always medically treat others. The individual or the family must remember that for the Christian, death is not the enemy. The enemy is mortal sin that brings separation from God. There are occasions when medical treatment can be morally rejected on the basis of the expense and torture it would put the patient through regardless of its ability to prolong life. Pope Pius XII is the frequently cited source for this perspective.

Natural reason and Christian morals say that man (and whoever is entrusted with the task of taking care of his fellowman) has the right and duty in case of serious illness to take the necessary treatment for the preservation of life and health. This duty that one has toward himself, toward God, toward the human community, and in most cases toward certain determined persons, derives from a well-ordered charity, from submission to the Creator, from social justice and even from strict justice as well as from devotion toward one’s family. But normally 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 great burdens for oneself or another. A stricter obligation would be too burdensome for most men and would render the attainment of a higher, more important good too difficult. Life, health, all temporary 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. (Pius XII 1957 November 24th. “Prolongation of Life: Allocution to an International Congress of Anesthesiologists.” The Pope Speaks 4:393-398.)

I would much rather close the discussion with the above point but it seems a bit cowardly not to address the issue of the feeding tube which occasioned this article. Most of us would prefer a cut and dry rule that would free us from having to consider the individual circumstances. “Just tell us what procedures can be done at what times.” The Florida Bishops were criticized recently for their hesitation in commenting directly on the morality of the decision by a husband to have his wife’s feeding tube removed. Until public pressure forced them to address the particular case, the bishops preferred to reiterate moral principals that must be applied to medical situations. The problem with publishing a judgment is that their opinion in a particular case can too easily be misread as a new rule and be applied to circumstances that are different than the case at hand. It is not true that in all circumstances feeding tubes must never be removed.

The Bishops of Wisconsin recently published a fine document entitled “Now and at the Hour of our Death.” In their document the bishops dealt with the very difficult issue of when a feeding tube, referred to as medically assisted nutrition, can be refused or even withdrawn. We should begin the discussion with the “presumption” stated in “The Ethical and Religious Directives for Catholic Health Care,” United Stated Conference of Catholic Bishops 2001, Directive # 58, that medically assisted nutrition and hydration should be given to all patients unless the burden to the patient outweighs the benefits.

It is important to note, as the bishops do, that the same principles apply whether one is refusing treatment or discontinuing a treatment. This means that the decision to withdraw a feeding tube is no different than the initial decision to refuse a feeding tube. It must be granted that emotionally there will be a different feel to the decision to remove a feeding tube rather than not to initiate the procedure, but both circumstances are dealing with a treatment that must be “presumed in favor of” the patient but at times will be morally refused initially or subsequently because of the burden it places on the patient or the family. It is easier to confuse removal of a feeding tube with active euthanasia, but according to the bishops “the cause of death is the pathology which required the initiation of life support in the first place.” (“Now and in the Hour of Our Death”). The above may seem hard to accept but essentially it is the injury or disease that has caused ordinary means of care, giving food and water, in some cases to become extraordinary.

Determining when ordinary care has become extraordinary is very difficult. It often involves assessing a large number of variables including pain, discomfort, the financial burden, and the emotional drain on the family, against frequently unpredictable benefits to the patient. Pius XII summarizes what can be considered extraordinary means.

Extraordinary means (not morally obligatory) are all medicine, treatments and operations that cannot be used or obtained without excessive expense, pain or other burden. (Pius XII 1957)

The end-of-life decisions are difficult and very important. We cannot over simplify an event that takes place in widely different circumstances among individuals whose capacities and resources vary. Instead of a rule that ignores the very real issues involved, Catholic teaching provides a very balanced view that rejects euthanasia while accepting the morality of refusing burdensome treatments. Death is not the answer to be sought or intended but neither is it to be avoided at all costs. The nature of life, including its sufferings, can prepare us for God and natural death is the final step towards the eternal context of human life.

 

Reverend John Balluff is a priest ordained for the Diocese of Joliet, Illinois, in 1988. He earned his doctorate in sacred theology from the Pontifical Gregorian University in Rome in 1995. Currently he serves as pastor for three small rural churches and a mission to Spanish speaking Catholics of the region.