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VATICAN LETTER Feb-29-2008 (1,080 words) Backgrounder. xxxi

Ambiguities cloud moral, medical issues as end of life nears

By Carol Glatz
Catholic News Service

VATICAN CITY (CNS) -- Many Catholics still need to learn about the church's teachings on end-of-life issues, such as when it might be morally acceptable to reject or terminate life-prolonging treatments, said some participants at a Vatican-sponsored congress.

While euthanasia and assisted suicide are always wrong, in some situations the terminally ill or dying can withdraw or refuse treatment and still be in line with church teaching.

To help people make informed and ethical decisions, "much work needs to be done in elaborating on the church's tradition of reasoning about forgoing life-prolonging treatments to make it practical for health care providers and persons who are dying," said Dr. William Sullivan, director of the Toronto-based International Association of Catholic Bioethicists.

Sullivan was one of hundreds of scholars, theologians, religious and health care professionals who turned out for the Pontifical Academy for Life's Feb. 25-26 international congress, which looked at the scientific and ethical aspects of caring for the terminally ill and dying.

The gathering was important because not only is the push for legalizing euthanasia and assisted suicide taking root in many parts of the world, but incurable, deadly diseases are also on the rise.

Several speakers noted that even some Catholics might not be clear about what kind of decisions are morally licit, since ambiguities cloud many end-of-life issues.

One difficulty lies in the fact that moral theologians and some medical professionals may be attaching different meaning to terms such as "ordinary," "extraordinary" and "futile" when describing a proposed treatment.

The Vatican's Congregation for the Doctrine of the Faith tried to clear up this problem with its 1980 Declaration on Euthanasia. The Vatican assigned the terms "proportionate" and "disproportionate" to describe the probable effectiveness of possible treatments. Whenever a medical treatment is deemed disproportionate because it would cause the patient strain or suffering out of proportion with the benefits, then it is optional.

And the U.S. Conference of Catholic Bishops issued its "Ethical and Religious Directives for Catholic Health Care Services" in 2001 to help "articulate and apply magisterial teaching," said John Haas, president of the National Catholic Bioethics Center in Philadelphia.

But some recent literature in moral theology has been ascribing new uses for the terms ordinary and proportionate -- developments that he said do not seem rooted in the way the church traditionally has used those terms. He said the church must continue to refine the terms "to allow a greater precision in ethical judgment."

Sullivan told Catholic News Service that living wills or advance medical directives are not always wrong in the eyes of the church.

One case where they might be morally licit, he said, is if a patient developing Alzheimer's disease makes a written request in advance to decline a feeding tube if he or she is refusing to eat because of the disease.

"Now that doesn't mean they are declining basic care. You would provide hand feeding as much as possible, but it is a legitimate advance directive to say that under those circumstances I may not want that intervention" of artificial feeding, he said.

Bishop Elio Sgreccia, president of the Pontifical Academy for Life, voiced a word of caution about advance directives in his written presentation.

While the directives help family members know what a patient considered extraordinary or excessive, Bishop Sgreccia said debates on living wills say "the merit of the validity of a document drawn up in advance" is questionable.

He said that from an ethical point of view, living wills "may not be obligatory for patients." The doctor should not be "bound by clauses" in the document "that he might judge unacceptable either for clinical or ethical reasons" and the document must "not contain directives of a euthanistic nature," he added.

While the bishop said a living will is an important method for letting patients try to avoid "excessive treatments of a therapeutically obstinate nature" and to pledge organ donation, the current tendency of such documents is to include directives "that take the form of the practice of euthanasia."

Haas told CNS that in the world of high-tech medical advancements "the really big area of contention today is this area of assisted nutrition and hydration."

This was made especially apparent during the legal battle over the fate of Terri Schindler Schiavo, a severely brain-damaged Florida woman who died in March 2005 after a court ordered that her husband could make her medical decisions for her. Michael Schiavo, the husband and legal guardian, said she would have wanted her feeding tube removed, while her parents said she would have wanted to remain alive based on her Catholic faith.

Bobby Schindler, Schiavo's brother and executive director of the Terri Schindler Schiavo Foundation, said he attended the Vatican congress "to keep educating myself on these issues."

He told CNS that while the case "raised an incredible amount of awareness," incomplete or misleading media coverage also generated "a tremendous amount of confusion" that still lingers.

Pope John Paul II's 2004 allocution said artificial feeding and nutrition of patients in a persistent vegetative state was not "a medical act," but was proportionate and ordinary and therefore morally obligatory.

But Schindler said these teachings are not being conveyed adequately. He said U.S. clergy were being too silent from "apathy or indifference" and not coming to their defense in time.

Much confusion, he said, is caused when the case mistakenly is "lumped into these end-of-life discussions when in fact it was not an end-of-life situation."

"Terri was not dying, the brain injury was not going to kill her," and she died just like anyone else would die "if they took away our food and water," Schindler said.

Haas said that during congress deliberations, Bishop Sgreccia stressed that the concept of "excessive burden has to be applied to the treatment and not to the life" of the patient.

It would be immoral for a person with a chronic condition or a substitute decision-maker to decide the patient's life has become "too burdensome" and to remove the necessary life support.

But, "if the person is dying and the continued use (of life-supporting measures) results in a prolonged and precarious existence, then clearly it can be withdrawn," Haas said.

"The difficulty is people want black-and-white answers," Haas said, "and when we are dealing with these end-of-life questions it's a matter of prudential judgment as to what is going to constitute a reasonable hope of benefit and excessive burden."


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