Agathanasia and the care of the dying Patrick M. Byrne, sj, ba,
m
div; Michael J. Stogre, sj, ba, ma,
Guttman,1 in concluding his recent essay "On withholding treatment", pre¬ sented the medical profession with a plea and a challenge: "Because there is always the possibility of error in prognosis, the choice we face in giving advice on withholding treatment is a difficult one, awesome in its finality. However, it is time that the medical profession discuss this issue openly, for not to do so commits us to a state of unpreparedness for the sudden presen¬ tation of this problem." Our intention is to call forth such a discussion. In this discussion our reflections issue from
a
Catholic-Christian "on-look",
but we have drawn on the insights of ethicians in other traditions. For this we make no apologies, believing that a healthy pluralism is needed to clarify and solve medical-moral questions. Medical advances have given man substantial control over illness and, to a large extent, a control of the dying process itself. Yet doctors are often confused when faced with the situation
of the dying patient. Should everything be done to prolong life at all costs? Should patients be spared a lengthy and painful death by removal of the life support systems? Or should we actively intervene and terminate the life directly? The central problem now is the nature of death, and a core issue consists of the criteria of death itself. When death meant the cessation of the flow of blood and breath, the cri¬ teria for determining the terminal point of life were quite simple.2 But with the advent of organ transplantation this definition became inadequate and death had to be redefined. And, in 1968, a group of doctors, lawyers, theologians, social scientists and biologists, under the direction of Beecher, undertook to determine valid criteria for pronouncing someone dead in the sense of being
m div
in an irreversible coma. The committee stated that the patient should be in deep and irreversible coma; manifest total unawareness to external painful stimuli; have no spontaneous muscular movements or elicitable reflexes; have pupils fixed, dilated and unresponsive to light; and have an isoelectric electro¬ encephalogram, with the foregoing characteristics having been maintained over a period of 24 hours.3 Beecher has reported that, with use of these criteria, no instance of coma reversal was noted in more than 3000 patients.3 There should be, then, univer¬ sal agreement that brain death is in¬ deed clinical death. In fact, "after brain death the sur¬ geon has the moral obligation to stop all artificial methods of sustaining life by artificial respirators."4 This needs to be qualified because we may want to use the body as a tissue bank. Given these considerations, how are we to deal with the issue of withhold¬ ing treatment? The dying process has been defined as that time in the course of an irre¬ versible illness when treatment will no longer influence it, so that death is inevitable.5 Just as a living man has the right to life, a dying person should have the right to die. Accordingly, the traditional and updated Catholic posision, referred to by Guttman, has been that neither ordinary (customary) nor
used without excessive ex¬ other inconvenience, or if used, would not offer a reasonable hope of benefit.7 obtained
or
pain,
or
In brief,
as
pense,
should be obvious, the should be whatever offers "a reasonable hope of success". But for this there is no readymade guide. As Aristotle noted long ago, when one is practising medicine, one should not look for the certitude avail¬ able in mathematics.27 We must make
operative principle
prudential judgement; and we must decisively, but not definitively. For what may mean inevitable death today may not be so tomorrow; a new drug, surgical technique, or other form of therapy may have then become avail¬ able. It can also happen that what are considered ordinary means could, in the case of the terminally ill patient, be prolongations of the dying process rather than aids to life. Therefore, the a
act
use of any means should be based on a "reasonable of cure. For ex¬ the use of oxygen and intra¬ venous to sustain life in for whom there is no reason¬ able of success is not these are understood as means. In there is no moral
hope" ample, feeding patients hope therapeutic obligatory, although normally ordinary brief, obligation to preserve life at all costs. Yet can the doctor ignore the wishes extraordinary (unusual) means are of the patient, either for prolongation obligatory in treatment unless there is or termination of his life? It is at this some hope of checking or curing the juncture that both doctor and patient illness.6 consider the assumptive value of "use¬ What is the basis of this distinction? fulness". But, in the words of Haring,s The following description will clarify "realization of significant liberty for its meaning: man in the total history of human free¬ dom and redemption absolutely preOrdinary means are all medicines, treat- cludes the impersonal criterion of 'use¬ ments, and operations which offer a
reasonable hope of benefit and which can be obtained and used without excessive pain, or other inconvenience. Extraor¬ Reprint requests to: Fr. Michael Stogre, Regis means are all medicines, treatdinary Ont. 3425 Bayview Ave., Willowdale, College, ments, and operations which cannot be M2M 3S5 1396 CMA JOURNAL/JUNE 21, 1975/VOL. 112
fulness' which branded the cruelties of Hitler." Life may not seem very "useful" but it has a dignity that transcends use. The wishes of the dying patient not
to have his dying prolonged artificially should be respected, even if one of the patient's chief motives is the financial concern of his or her family. The essential motivation of the patient is love and concern.9 Originally "euthanasia" meant a painless or happy death, without any connotation of death being induced. However, in the 20th century the word is used to refer to a "theory that in certain circumstances, when owing to disease, senility or the like, a person's life has permanently ceased to be agreeable or useful, the sufferer should be painlessly killed, either by himself or by another."10 Fletcher,'0 while advocating this approach, has also distinguished between "positive" and "negative" euthanasia. The latter does not involve any direct acts that would bring death, but rather it consists in omitting actions and discontinuing procedures that maintain a patient's life. The former consists of direct actions designed to terminate life. To help us out of the maze of terminology and distinctions, Ramsay," the Protestant moralist, has suggested the alternative term "agathanasia". This new term, which combines the Greek adjective agathos, meaning good, and the noun thanatos, meaning death, is free of those emotional connotations of the word "euthanasia" that often preclude intelligent discussion of the issue. Ramsay uses this term to refer to a death with dignity, and to describe activities that Fletcher would term negative euthanasia. Thus Fletcher and Ramsay .joined in a dialectic concerning the validity of the distinction between negative and positive (activepassive) euthanasia and its usefulness to physicians. Fletcher maintains that the distinction is at best meaningless for the end intended. The patient's death is the same either way: "if we will the end we will the means."12 Because Fletcher's view is important for ethics in general and medical ethics in particular, let us summarize his ethical theory. He is a "consequentialist". In his own words, "We reason from the data of each actual case or problem and then choose the course that offers an optimum or maximum of desirable consequences"; furthermore, "results are what counts, and results are good when they contribute to human well-being",13 a point to be situationally determined. In addition to the consequential aspect of his theory Fletcher stresses the importance of intention.14 The Christian is called to have compassion on those of his brothers who are terminally ill, for "mercy is a value or virtue born of personal growth and moral stature, a thing of the spirit alto-
gcther."'5 Freedom, moreover, is also a value for him: In the personalistic view of man and morals, asserted throughout these pages personality is supreme over mere life. To prolong life uselessly, while the personal qualities of freedom, knowledge, self-possession and control, and responsibility are sacrificed is to attack the moral status of a person.16 Many moralists, like Curran, Ramsay and Haring, although they would condemn positive euthanasia and advocate an ethics of agathanasia, would share with Fletcher the concern for the values of compassion and human freedom. Yet how we as human and moral agents achieve these values is equally important. An ethics of agathanasia is concerned with means as much as with consequences. The good consequences intended by a man are not sufficient to justify his actions. The action itself that brings about the desirable consequences carries with it a meaning that is crucial within the context of the morality of the whole activity. It is with this in mind that Ramsay has stated that "to do or not to do something may, then, be subject to different moral evaluations."17 Even if the actions lead to the same end result for example, the death of the patient - one action may be morally preferable. Furthermore, from a consequential perspective another question is important for Fletcher and for the medical profession: What would be the long-term consequences for doctorpatient relations if positive euthanasia were to become accepted? Would it not destroy a context of trust already fragile and so essential to the healing mission of medicine? We have been abstract and general; let us now be concrete and particular. Although the administration of a lethal dose of a drug and the discontinuation of an intravenous infusion are both deliberate acts with the same consequence - the patient's death - there is an important difference between them. Giving the lethal dose kills the patient; stopping life-sustaining procedures that have no reasonable hope of success is to allow the patient to die. In the latter case no human agent causes the patient's death, either directly or indirectly. "He dies his own death from causes that it is no longer merciful or reasonable to fight by medical intervention";18 and, "In caring for the dying, we cease doing what was once called for and begin to do what is now called for".19 And so in Roman Catholic moral tradition, which Ramsay builds on, there has been a concern to care for the comfort of the patient.
There has been no reluctance, therefore, in advocating treatments intended to relieve excessive pain, even though the patient's life may be shortened as a result. And because terminal pain can to a large extent be relieved, let us not hesitate to use, for example, necessary medication or hypnosis to control consciousness of pain. The distinction between negative and positive euthanasia seems to retain its validity in the description of the moral activity involved in these cases. Likewise, the distinction between use of drugs to induce death and their use to relieve pain - even though life be shortened - also is valid. And, noting the qu.difier that terminal life cannot be considered similar to prenatal or neonatal life, these same distinctions obtain and apply, for example, to special-care nursery situations.20-25 As we ourselves learned in courses on human sexuality, human beings need permission to be sexual beings. So too, perhaps, the medical profession needs a symbolic clerical permission to practice an ethics of agathanasia an ethics that recognizes that human freedom cannot claim to be absolute but has certain constraints that, in the end, enable human beings to be humanly compassionate before the pains of death and humanly free to receive it.26 References 1. GUiTMAN FM: On withholding treatment. Can Med Assoc 1 111: 523, 1974 2. RAM5AY P: The Patient as Person. New Haven, Yale, 1970, pp 59-60
3. BEECHER HK (chmn): A definition of irreversible coma. Report of the ad hoc committee of the Harvard medical school to examine the definition of brain death. JAMA 205: 337, 1968 4. HARING B: Medical Ethics. Slough, St. Paul
Publ, 1972, p 133 5, CAVANAUGH J: Bene mon: the right patient to die with dignity. Linacre 60, 1963 6. KELLY G: The duty of using artificial of preserving life. Theol Stud 11: 203,
of the Q 30: means 1950
7. Idem: The duty to preserve life. Theol Stud
12: 550, 1951
8. HARING B: Medical Ethics. op cit, p 142
9. Ibid, p 143 10. FLETCHER J: Morals and Medicine. Boston, Beacon, 1972, p 172 11. RAMsAY: The Patient as Person. op cit, p 149 12. FLETCHER J: The patient's right to die. Harper's, Oct 1960, p 143 13. Idem: Ethical aspects of genetic controls. N Engl I Med 285: 777, 1971 14. FLETCHER 3: Morals and Medicine. op cit, p 186 15. Ibid, pp 181-84 16. Ibid, p 191 17. RAM5AY: The Patient as Person. op cit, p 151 18. Ibid, p 151 19. Ibid, p 159 20. DUFF RS, CAMPBELL AGM: Moral and ethical dilemmas in the special-care nursery. N Engl I Med 289: 890, 1973 21. REscH WT: On the birth of a severely handicapped infant, in Hastings Center Report, 1973, pp 10-12 22. SHURTLEFF DB, HAYDEN PW, LOESER JD, et al: Myelodysplasia: decision for death or disability. N Engl I Med 291: 1005, 1974 23. McCoRMIcK RA: To save or let die: the dilemma of modem medicine. JAMA 229:
172, 1974 24. FLETCHER 3: Abortion, euthanasia, and care of defective newborns. N Engl I Med 292: 75, 1975
25. RACHELS 3: Active and passive euthanasia.
Ibid, p 78 26. HARING B: Medical Ethics. op cit, pp 141-43
27. ARIsTOTLE: Ethics, translated by ROCHKOM H,
edited by THOMSON JAK, Baltimore, Penguin, 1963
CMA JOURNAL/JUNE 21, 1975/VOL. 112 1397
m
div; Michael J. Stogre, sj, ba, ma,
Guttman,1 in concluding his recent essay "On withholding treatment", pre¬ sented the medical profession with a plea and a challenge: "Because there is always the possibility of error in prognosis, the choice we face in giving advice on withholding treatment is a difficult one, awesome in its finality. However, it is time that the medical profession discuss this issue openly, for not to do so commits us to a state of unpreparedness for the sudden presen¬ tation of this problem." Our intention is to call forth such a discussion. In this discussion our reflections issue from
a
Catholic-Christian "on-look",
but we have drawn on the insights of ethicians in other traditions. For this we make no apologies, believing that a healthy pluralism is needed to clarify and solve medical-moral questions. Medical advances have given man substantial control over illness and, to a large extent, a control of the dying process itself. Yet doctors are often confused when faced with the situation
of the dying patient. Should everything be done to prolong life at all costs? Should patients be spared a lengthy and painful death by removal of the life support systems? Or should we actively intervene and terminate the life directly? The central problem now is the nature of death, and a core issue consists of the criteria of death itself. When death meant the cessation of the flow of blood and breath, the cri¬ teria for determining the terminal point of life were quite simple.2 But with the advent of organ transplantation this definition became inadequate and death had to be redefined. And, in 1968, a group of doctors, lawyers, theologians, social scientists and biologists, under the direction of Beecher, undertook to determine valid criteria for pronouncing someone dead in the sense of being
m div
in an irreversible coma. The committee stated that the patient should be in deep and irreversible coma; manifest total unawareness to external painful stimuli; have no spontaneous muscular movements or elicitable reflexes; have pupils fixed, dilated and unresponsive to light; and have an isoelectric electro¬ encephalogram, with the foregoing characteristics having been maintained over a period of 24 hours.3 Beecher has reported that, with use of these criteria, no instance of coma reversal was noted in more than 3000 patients.3 There should be, then, univer¬ sal agreement that brain death is in¬ deed clinical death. In fact, "after brain death the sur¬ geon has the moral obligation to stop all artificial methods of sustaining life by artificial respirators."4 This needs to be qualified because we may want to use the body as a tissue bank. Given these considerations, how are we to deal with the issue of withhold¬ ing treatment? The dying process has been defined as that time in the course of an irre¬ versible illness when treatment will no longer influence it, so that death is inevitable.5 Just as a living man has the right to life, a dying person should have the right to die. Accordingly, the traditional and updated Catholic posision, referred to by Guttman, has been that neither ordinary (customary) nor
used without excessive ex¬ other inconvenience, or if used, would not offer a reasonable hope of benefit.7 obtained
or
pain,
or
In brief,
as
pense,
should be obvious, the should be whatever offers "a reasonable hope of success". But for this there is no readymade guide. As Aristotle noted long ago, when one is practising medicine, one should not look for the certitude avail¬ able in mathematics.27 We must make
operative principle
prudential judgement; and we must decisively, but not definitively. For what may mean inevitable death today may not be so tomorrow; a new drug, surgical technique, or other form of therapy may have then become avail¬ able. It can also happen that what are considered ordinary means could, in the case of the terminally ill patient, be prolongations of the dying process rather than aids to life. Therefore, the a
act
use of any means should be based on a "reasonable of cure. For ex¬ the use of oxygen and intra¬ venous to sustain life in for whom there is no reason¬ able of success is not these are understood as means. In there is no moral
hope" ample, feeding patients hope therapeutic obligatory, although normally ordinary brief, obligation to preserve life at all costs. Yet can the doctor ignore the wishes extraordinary (unusual) means are of the patient, either for prolongation obligatory in treatment unless there is or termination of his life? It is at this some hope of checking or curing the juncture that both doctor and patient illness.6 consider the assumptive value of "use¬ What is the basis of this distinction? fulness". But, in the words of Haring,s The following description will clarify "realization of significant liberty for its meaning: man in the total history of human free¬ dom and redemption absolutely preOrdinary means are all medicines, treat- cludes the impersonal criterion of 'use¬ ments, and operations which offer a
reasonable hope of benefit and which can be obtained and used without excessive pain, or other inconvenience. Extraor¬ Reprint requests to: Fr. Michael Stogre, Regis means are all medicines, treatdinary Ont. 3425 Bayview Ave., Willowdale, College, ments, and operations which cannot be M2M 3S5 1396 CMA JOURNAL/JUNE 21, 1975/VOL. 112
fulness' which branded the cruelties of Hitler." Life may not seem very "useful" but it has a dignity that transcends use. The wishes of the dying patient not
to have his dying prolonged artificially should be respected, even if one of the patient's chief motives is the financial concern of his or her family. The essential motivation of the patient is love and concern.9 Originally "euthanasia" meant a painless or happy death, without any connotation of death being induced. However, in the 20th century the word is used to refer to a "theory that in certain circumstances, when owing to disease, senility or the like, a person's life has permanently ceased to be agreeable or useful, the sufferer should be painlessly killed, either by himself or by another."10 Fletcher,'0 while advocating this approach, has also distinguished between "positive" and "negative" euthanasia. The latter does not involve any direct acts that would bring death, but rather it consists in omitting actions and discontinuing procedures that maintain a patient's life. The former consists of direct actions designed to terminate life. To help us out of the maze of terminology and distinctions, Ramsay," the Protestant moralist, has suggested the alternative term "agathanasia". This new term, which combines the Greek adjective agathos, meaning good, and the noun thanatos, meaning death, is free of those emotional connotations of the word "euthanasia" that often preclude intelligent discussion of the issue. Ramsay uses this term to refer to a death with dignity, and to describe activities that Fletcher would term negative euthanasia. Thus Fletcher and Ramsay .joined in a dialectic concerning the validity of the distinction between negative and positive (activepassive) euthanasia and its usefulness to physicians. Fletcher maintains that the distinction is at best meaningless for the end intended. The patient's death is the same either way: "if we will the end we will the means."12 Because Fletcher's view is important for ethics in general and medical ethics in particular, let us summarize his ethical theory. He is a "consequentialist". In his own words, "We reason from the data of each actual case or problem and then choose the course that offers an optimum or maximum of desirable consequences"; furthermore, "results are what counts, and results are good when they contribute to human well-being",13 a point to be situationally determined. In addition to the consequential aspect of his theory Fletcher stresses the importance of intention.14 The Christian is called to have compassion on those of his brothers who are terminally ill, for "mercy is a value or virtue born of personal growth and moral stature, a thing of the spirit alto-
gcther."'5 Freedom, moreover, is also a value for him: In the personalistic view of man and morals, asserted throughout these pages personality is supreme over mere life. To prolong life uselessly, while the personal qualities of freedom, knowledge, self-possession and control, and responsibility are sacrificed is to attack the moral status of a person.16 Many moralists, like Curran, Ramsay and Haring, although they would condemn positive euthanasia and advocate an ethics of agathanasia, would share with Fletcher the concern for the values of compassion and human freedom. Yet how we as human and moral agents achieve these values is equally important. An ethics of agathanasia is concerned with means as much as with consequences. The good consequences intended by a man are not sufficient to justify his actions. The action itself that brings about the desirable consequences carries with it a meaning that is crucial within the context of the morality of the whole activity. It is with this in mind that Ramsay has stated that "to do or not to do something may, then, be subject to different moral evaluations."17 Even if the actions lead to the same end result for example, the death of the patient - one action may be morally preferable. Furthermore, from a consequential perspective another question is important for Fletcher and for the medical profession: What would be the long-term consequences for doctorpatient relations if positive euthanasia were to become accepted? Would it not destroy a context of trust already fragile and so essential to the healing mission of medicine? We have been abstract and general; let us now be concrete and particular. Although the administration of a lethal dose of a drug and the discontinuation of an intravenous infusion are both deliberate acts with the same consequence - the patient's death - there is an important difference between them. Giving the lethal dose kills the patient; stopping life-sustaining procedures that have no reasonable hope of success is to allow the patient to die. In the latter case no human agent causes the patient's death, either directly or indirectly. "He dies his own death from causes that it is no longer merciful or reasonable to fight by medical intervention";18 and, "In caring for the dying, we cease doing what was once called for and begin to do what is now called for".19 And so in Roman Catholic moral tradition, which Ramsay builds on, there has been a concern to care for the comfort of the patient.
There has been no reluctance, therefore, in advocating treatments intended to relieve excessive pain, even though the patient's life may be shortened as a result. And because terminal pain can to a large extent be relieved, let us not hesitate to use, for example, necessary medication or hypnosis to control consciousness of pain. The distinction between negative and positive euthanasia seems to retain its validity in the description of the moral activity involved in these cases. Likewise, the distinction between use of drugs to induce death and their use to relieve pain - even though life be shortened - also is valid. And, noting the qu.difier that terminal life cannot be considered similar to prenatal or neonatal life, these same distinctions obtain and apply, for example, to special-care nursery situations.20-25 As we ourselves learned in courses on human sexuality, human beings need permission to be sexual beings. So too, perhaps, the medical profession needs a symbolic clerical permission to practice an ethics of agathanasia an ethics that recognizes that human freedom cannot claim to be absolute but has certain constraints that, in the end, enable human beings to be humanly compassionate before the pains of death and humanly free to receive it.26 References 1. GUiTMAN FM: On withholding treatment. Can Med Assoc 1 111: 523, 1974 2. RAM5AY P: The Patient as Person. New Haven, Yale, 1970, pp 59-60
3. BEECHER HK (chmn): A definition of irreversible coma. Report of the ad hoc committee of the Harvard medical school to examine the definition of brain death. JAMA 205: 337, 1968 4. HARING B: Medical Ethics. Slough, St. Paul
Publ, 1972, p 133 5, CAVANAUGH J: Bene mon: the right patient to die with dignity. Linacre 60, 1963 6. KELLY G: The duty of using artificial of preserving life. Theol Stud 11: 203,
of the Q 30: means 1950
7. Idem: The duty to preserve life. Theol Stud
12: 550, 1951
8. HARING B: Medical Ethics. op cit, p 142
9. Ibid, p 143 10. FLETCHER J: Morals and Medicine. Boston, Beacon, 1972, p 172 11. RAMsAY: The Patient as Person. op cit, p 149 12. FLETCHER J: The patient's right to die. Harper's, Oct 1960, p 143 13. Idem: Ethical aspects of genetic controls. N Engl I Med 285: 777, 1971 14. FLETCHER 3: Morals and Medicine. op cit, p 186 15. Ibid, pp 181-84 16. Ibid, p 191 17. RAM5AY: The Patient as Person. op cit, p 151 18. Ibid, p 151 19. Ibid, p 159 20. DUFF RS, CAMPBELL AGM: Moral and ethical dilemmas in the special-care nursery. N Engl I Med 289: 890, 1973 21. REscH WT: On the birth of a severely handicapped infant, in Hastings Center Report, 1973, pp 10-12 22. SHURTLEFF DB, HAYDEN PW, LOESER JD, et al: Myelodysplasia: decision for death or disability. N Engl I Med 291: 1005, 1974 23. McCoRMIcK RA: To save or let die: the dilemma of modem medicine. JAMA 229:
172, 1974 24. FLETCHER 3: Abortion, euthanasia, and care of defective newborns. N Engl I Med 292: 75, 1975
25. RACHELS 3: Active and passive euthanasia.
Ibid, p 78 26. HARING B: Medical Ethics. op cit, pp 141-43
27. ARIsTOTLE: Ethics, translated by ROCHKOM H,
edited by THOMSON JAK, Baltimore, Penguin, 1963
CMA JOURNAL/JUNE 21, 1975/VOL. 112 1397
