In assessing when there is a duty to preserve life, the Church distinguishes between ordinary and extraordinary means.[1] Ordinary means must be taken to preserve life, and extraordinary means can be morally refused.[2] It is, therefore, critical to properly characterize particular means of preserving human life as ordinary or extraordinary, that is, as morally obligatory or non-morally obligatory.
To further clarify, extraordinary means are “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.”[3] In contrast, ordinary means are those “means of treatment available [that] are objectively proportionate to the prospects for improvement.”[4] There are, however, various factors that assist in the determination of what is ordinary and what is extraordinary. Such factors include: “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.”[5]
For example, a feeding tube is an ordinary means of preserving life.[6] This is evident when the factors listed above to differentiate ordinary and extraordinary means are applied. Regarding the type of treatment to be used, a feeding tube is, strictly speaking, not medical treatment at all. It is the basic provision of natural food to which all human beings require and are entitled to by virtue of their humanity. Since a feeding tube is entirely outside the scope of medical care altogether, there is no need to apply the other elements to conclude that it is an ordinary means, but for the sake of thoroughness, the application of the remaining elements demonstrates that a feeding tube is an ordinary means of preserving life. There is nothing complex or risky about using a feeding tube. Given our health system in the United States, it may be costly, but is easy to use. The clear result is that the patient will not starve to death, which is worth all the physical and moral resources[7] a person can afford. Having concluded, then, that a feeding tube is ordinary care, the denial of a feeding tube which results in the death of a patient by starvation can be a form of euthanasia, provided that the motivation in denying the feeding tube is the relief of suffering and the person who removed the feeding tube intended the death of the patient.[8] In any event, starving someone to death with the evident intention to kill him/her is murder.[9]
While the distinction between ordinary and extraordinary means of preserving life can be rationally applied to any fact pattern and produce a reasonable result, there are those who argue that euthanasia—killing a patient to relieve his/her pain—is morally equivalent to letting a patient die by refusing to administer extraordinary care.[10] This position endangers human life because it creates confusion regarding the essential question of when there is a duty to preserve human life. This confusion can then be used to justify euthanasia. Since the death of the patient results in both cases, it is, perhaps, understandable why some have a difficult time seeing the moral distinction between euthanasia and letting die.
But a consequentialist[11] bioethics that looks strictly at the consequences of moral acts is incompatible with the nature of the human person. This incompatibility is evident, for example, when we look at the way courts sentence criminals for acts of killing. A criminal who premeditated killing another person and devised a careful scheme to affect his unlawful plan is likely to receive a more severe sentence than a second criminal who witnesses a provocative scene likely to inflame his emotions and then unintentionally kills someone in a furious rage, e.g., the classic example of the man who witnesses his wife committing adultery and then kills her in the heat of passion. Although death resulted in both cases, the first criminal intended to kill another person in a cool, calculated manner and acted accordingly, whereas the second criminal acted on his emotions on the spur of the moment without ever intending to kill another person. The first criminal clearly committed murder, the “unlawful killing of a human being with malice aforethought.”[12] The second criminal probably committed the lesser crime of manslaughter, “the unlawful killing of a human being without malice or premeditation.”[13] Thus, the law attributes significance to intentions. Morality, too, like law, attributes significance to intentions.[14] Consequently, in addition to considering the obvious consequence of euthanasia and that of letting a person die by not administering extraordinary care—the death of the patient in both cases—we need to look at the intention behind euthanasia and the intention behind allowing a person to die without administering extraordinary care. However, since the intention behind an action is commingled with various other considerations, the intention should not be isolated from the overall context of an action. To analyze intentions in a meaningful way, we can apply the principle of double effect.
The moral principle of double effect provides that, in order for an action to be morally legitimate, four conditions must be satisfied:[15]
[1] The intended act must be good in itself [or at least morally neutral]. The intended act may not be morally evil.
[2] The good effect of the act must be that which is directly intended by the one who carries out the act. The bad effect that results from the act may be foreseen by the agent but must be unintended.
[3] The good effect must not be brought about by using morally evil means [i.e., the ends do not justify the means].
[4] The good effect must be of equal or greater proportion to any evil effect which would result. [If the good effect can be accomplished without the evil effect, then the evil effect is not morally permissible. In addition, to the extent that the evil effect can be mitigated while still accomplishing the good effect, such mitigation is morally required].[16]
These conditions, when applied to euthanasia—intentionally killing a patient with the motive to relieve his/her suffering—lead to the conclusion that euthanasia is not morally justified. (1) Firstly, in euthanasia, the intended act is the killing of a human being for the purpose of relieving his/her pain,[17] a purpose which neither falls within self defense or defense of others. As the intentional killing of a human being outside of self-defense and defense of others is intrinsically evil, euthanasia is morally indefensible. For the sake of thoroughness, the remaining conditions can be applied. (2) Secondly, the good effect of euthanasia—the relief of pain—is not directly intended, but rather, this effect results from the realization of the primary intention to kill the patient. Furthermore, the bad effect of euthanasia-the death of the patient—is not simply foreseen, but intended, that is, the intent to kill the patient is necessarily an intent to cause the bad effect of the patient’s death. Therefore, euthanasia also violates the second condition. (3) Moreover, the good effect of euthanasia is brought about by an evil means, the killing of the patient.[18] So euthanasia also violates the third condition. (4) Finally, the good effect of relieving pain is substantially outweighed by the much greater bad effect of killing the patient. Moreover, pain killers can be administered to the patient which alleviate pain without resulting in his/her death. Thus, if the relief of pain is desired, there is no need to kill the patient. Consequently, euthanasia also violates the fourth condition of the principle of double effect. Euthanasia is then a violation of all four conditions necessary to render an action morally legitimate.
In contrast, simply letting a patient die through not administering extraordinary means fulfills all four conditions of double effect, and is, therefore, morally legitimate. (1) Firstly, the intended act in withholding extraordinary care that is either futile or would impose a burden on the patient disproportionate to any expected benefits is to ensure the comfort of the patient in his/her remaining days on earth, not to kill the patient.[19] In withholding extraordinary care, there is no built-in-intention[20] to kill the patient because the death of the patient does not result from the withholding of medical care, but from the patient’s underlying ailment. Thus, a doctor who withholds extraordinary treatment is not causing the patient’s death. Moreover, the intended act of withholding extraordinary medical treatment is not morally evil. At worst, this action is morally neutral. Consequently, letting the patient die by withholding extraordinary care satisfies the first condition. (2) Secondly, the good effect of withholding extraordinary treatment is that the patient will be more comfortable during his/her remaining time on earth. The bad effect is that the patient may die sooner than he/she otherwise would have. Here, the good effect, the comfort of the patient, is directly intended and does not depend upon the quicker death of the patient. In addition, while the bad effect is foreseen, as the doctor who withholds extraordinary care knows that the patient will die, this bad effect is not intended. Thus, the second condition of double effect is fulfilled. (3) Thirdly, the quicker death of the patient is not, in fact, the means by which the good effect–the comfort of the patient during his/her remaining days on earth—is realized. This is clearly evidenced by the fact that the good effect, the comfort of the patient, occurs in time before the bad effect—the quicker death of the patient. Moreover, in no way is the bad effect, the quicker death of the patient, a cause of the good effect, the comfort of the patient. Thus, the bad effect, the death of the patient, is neither temporally nor causally prior to the good effect, the comfort of the patient. Therefore, the good effect—the comfort of the patient—is not brought about by using morally evil means. Accordingly, the third condition is fulfilled. (4) Finally, the good effect, the comfort of the patient—is not substantially outweighed by the bad effect, the quicker death of the patient. This is particularly true when it is considered that while human life has intrinsic value, it is but a preparation for eternal life. Furthermore, the death of the patient can only be delayed and is inevitable. Accordingly, the death that eventually does occur, albeit sooner that it would have were extraordinary care used, cannot be mitigated (delayed) without sacrificing the good effect, the comfort of the patient. The quicker death of the patient is necessary to allow the patient to spend his/her remaining days in comfort. Consequently, since the good effect is relatively proportional to the bad effect and since the bad effect is necessary and cannot be mitigated without sacrificing the good effect, the fourth condition of double effect is also satisfied. Therefore, allowing a patient to die by withholding extraordinary care satisfies all four conditions of double effect, rendering that action morally legitimate.[21]
Since euthanasia, including withholding ordinary care,[22] is morally unjustifiable under the principle of double effect, whereas withholding extraordinary care, i.e., letting die, is morally justifiable under that same principle, it is evident that the distinction the Magisterium[23] draws between ordinary and extraordinary care is not arbitrary.[24] We must, therefore, not allow this teaching to be undermined by the confusion of ordinary and extraordinary care. Otherwise, such confusion can lead to the deaths of millions of our brothers and sisters by euthanasia.
MICHAEL VACCA is a devotee of the Sacred Heart of Jesus and St. Therese of Lisieux. He graduated from Hillsdale College with a B.A. in English and Political Science, holds a J.D. from Ave Maria School of Law, and is a licensed attorney in Michigan. He currently serves as Director of Ministry, Bioethics, and Member Experience for Christ Medicus Foundation CURO. He worked for the Pontifical Council of the Family in Rome, where he advised the Church on pro-life and pro-family issues and advanced Catholic social teaching throughout the world. Michael is the Managing Editor of the International Center on Law, Life, Faith, and Family, which produces and provides resources on these issues, www.icolf.org. He is a founding board member of Sidewalk Advocates for Life, and currently serves on the board of the Casa Vitae Foundation. He is author and coauthor of various articles on bioethics and law, including: Michael Vacca, A Reexamination of Conscience Protections in Healthcare, 62 MEDICINA E MORALE 78 (2013) ; Jane Adolphe & Michael Vacca, Best Practices: Laws Protecting Human Life and the Family Around the Globe, 2 AVE MARIE INT’L L. J. 1 (2012); Michael Vacca, Talk About a Human Rights Violation: How Heterologous Assisted Reproduction Harms Children and Violates International Human Rights Law, 7 AVE MARIE INT’L L. J. 53 (2018); Michael Vacca, Natural Law as Guardian of the Human Person, 4 BAKU ST. UNIV. L. REV. 149 (2018); and Michael Vacca, Education and Religious Freedom in the Toledo Guiding Principles: A Comparative Analysis Between the Holy See and the United States 36 ARIZONA JOURNAL OF INTERNATIONAL AND COMPARATIVE LAW 2 (2019). He is also a co-editor of two published books, ST. PAUL, THE NATURAL LAW, AND CONTEMPORARY LEGAL THEORY (2012) and EQUALITY AND NON-DISCRIMINATION CATHOLIC ROOTS, CURRENT CHALLENGES (2019). More than anything, Michael is grateful to know the love of Jesus Christ and for his beautiful and holy wife Sarah.
Excerpted from “Threats to the Sanctity of Human Life,” Catholic Journal, 11/11/2019, https://www.catholicjournal.us/2019/11/11/threats-to-the-sanctity-of-human-life/. Reprinted by the Healthcare Advocacy and Leadership Organizations (HALO) with permission of the author.
Endnotes
[1] Pope Pius XII, Address to an International Congress of Anesthesiologists (24 November 1957). Also, sometimes the distinction between ordinary and extraordinary means is discussed in terms of proportionate and disproportionate means.
[2] Id.
[3] Pope John Paul II, Evangelium Vitae, § 65.
[4] Id.
[5] Sacred Congregation for the Doctrine of the Faith, Declaration on Euthanasia, IV. Due Proportion in the Use of Remedies (5 May 1980).
[6] “One must always provide ordinary care (including artificial nutrition and hydration), palliative treatment, especially the proper therapy for pain, in a dialogue with the patient which keeps him informed.” Pontifical Academy for Life, Respect for the Dignity of the Dying, § 6 (9 December 2000). Again, “The administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life.” Sacred Congregation for the Doctrine of the Faith, Responses to Certain Questions Concerning Artificial Nutrition and Hydration (1 August 2007).
[7] By moral resources, I am referring to a person’s virtues and positive attitude in the face of difficulties.
[8] Any reasonable person knows that removing a feeding tube from a patient will lead to his/her death.
[9] The qualification of the above analysis is that a feeding tube is morally obligatory so long as “it is shown to accomplish its proper finality, which is the hydration and nourishment of the patient.” Sacred Congregation for the Doctrine of the Faith, Responses to Certain Questions Concerning Artificial Nutrition and Hydration (1 August 2007). There are, then, conceivable situations when a feeding tube would not be ordinary care, but this is an exception to the principle that a feeding tube is ordinary care.
[10] In fact, the withholding of extraordinary treatment, that is, letting the patient die, is sometimes referred to as “passive euthanasia.” Cf. Freedom and dignity: in life and in death (18 Jan. 2011), available at http://synapses.co.za/freedom-dignity-life-death/ (last visited 14 October 2019).
[11] The view of consequentialism “holds that whether an act is morally right depends only on the consequences of that act or of something related to that act, such as the motive behind the act or a general rule requiring acts of the same kind.” Sinnott-Armstrong, Walter, Consequentialism, The Stanford Encyclopedia of Philosophy (Fall 2008 Edition), Edward N. Zalta (ed.), available at http://plato.stanford.edu/archives/fall2008/entries/consequentialism/ (last visited 14 October 2019).
[12] Murder, available at http://legal-dictionary.thefreedictionary.com/murder (last visited 14 October 2019),
[13] Manslaughter, available at http://www.lectlaw.com/def2/m013.htm (last visited 14 October 2019).
[14] If intentions had no moral implications, a deep examination of conscience that seeks to determine the true intentions behind certain behaviors would not be spiritually beneficial. We know from experience, however, that a deep examination of conscience is spiritually beneficial in part because it helps to illuminate our true intentions.
[15] All four conditions must be satisfied for an action to be moral.
[16] Cf. Catholic Dictionary, DOUBLE EFFECT, available at https://www.catholicculture.org/culture/library/dictionary/index.cfm?id=33215(last visited 14 October 2019).
[17] But despite the evident intention of the person who euthanizes the patient, many in society will defend the killing on the ground that the intention was not to kill the patient, but to end the victim’s suffering. This, however, is a false and misleading claim that confuses intention and motive. Intent refers to what a person contemplates doing, whereas motive refers to why they are doing it or the purpose for which they are doing it. The motive of the person who performs the lethal injection is to relieve the pain of the patient, but the obvious intention behind the lethal injection and the only possible ensuing result is the death of the victim. The intent to kill is built-in to the very act of euthanasia.
[18] This killing occurs outside the parameters of self-defense and defense of others, so it is unjustified and intrinsically evil.
[19] Cf. Will Cartwright, Killing and letting die: a defensible distinction, British Medical Bulletin; 1996; 52 (No. 2), available at http://bmb.oxfordjournals.org/content/52/2/354.full.pdf (last visited 14 October 2019).
[20] By the phrase “built-in intention,” I am referring to an intent that is clearly evident when simply looking at the action itself, that is, the intent is “built-in” to the action itself.
[21] In contrast, withholding ordinary care, which there is a duty to provide, is morally equivalent to euthanasia. In the case of a feeding tube, it is precisely the withholding of the feeding tube that results in the death of the patient by starvation, instead of the patient dying as a result of their preexisting ailment. Thus, the withdrawal of a feeding tube, in contrast to extraordinary care, causes the death of the patient.
[22] Withholding ordinary care is euthanasia by omission.
[23] The teaching office of the Catholic Church exercised by the Pope, the successor of St. Peter, throughout history, by virtue of the privilege handed down to him by Jesus in Matthew 16:18-19.
[24] The teaching of Pope Pius XII on the administration of pain medicine should also be carefully distinguished from euthanasia. Specifically, the administration of pain medicine which is intended to relieve pain but has the incidental effect of shortening death is, in principle, morally licit provided there is no “direct causal bond” between the administration of the pain medicine and the death of the person receiving the medicine. Cf. Pope Pius XII, Allocution to Doctors on the Moral Problems of Analgesia (24 February 1957), available at http://feamc.eu/wp-content/uploads/2018/06/pius12-feb1957.pdf (last visited 14 October 2019).
[1] https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities
[2] https://www.cms.gov/files/document/covid-hospital-visitation-phase-ii-visitation-covid-negative-patients.pdf