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EXTRA-ORDINARY MEANS
There is a great deal of
debate about extraordinary means. Perhaps a few words from someone who has
practiced medicine, surgery and psychiatry may help to clarify the issues. This
should not be considered a reflection on any current case.
The fundamental principle
that determines whether a given treatment is extraordinary is whether or not
what is being treated is reversible. To maintain and prolong the life of a
terminal patient by artificial means is like beating a dead or dying horse.
Such never prolongs life – rather it only prolongs the process of dying.
If the situation is unclear
as to whether the individual is terminal or not, (not as common as some would
think), it behooves the physician to consult with the patient and family, and
then to use his best judgment – a judgment honed by experience and
maturity. In such cases a physician will
often seek the opinion of a fellow practitioner.
Consider the use of a
ventilator (respirator). A patient with a treatable pulmonary infection or Guillain Barre syndrome
may be placed on a ventilator in anticipation of recovery. In a similar manner,
a patient in irreversible respiratory failure without hope of recovery may also
be placed on a ventilator. In the first case one saving a life; in the second
one is only prolonging the process of dying. It is clearly the intention and
the situation and not the technique which determines whether or not the means
is extraordinary.
Again, consider the decision
to use a feeding tube. In an individual who has reversible coma such as can
result from a car accident, the use of a temporary feeding tube is both
legitimate and necessary. Somewhat different is the use of a feeding tube in a
patient with confirmed irreversible coma. Similarly, terminal cancer patients
often fail to take in sufficient nutrition.
The refusal of such patients to eat is part of the involution that occurs approaching death.
Force feeding them is in some ways a cruel act. (Providing enough water
to maintain a reasonable level of comfort is another matter, for keeping the
individual comfortable is always to be desired.[1])
There are then situations where the physician and or the patient decides
that no further medical intervention is inappropriate, where the natural
process of dying should be allowed to take its normal course. In an earlier
time it was said that “pneumonia was the old man’s friend.” Such is the basis
of the oft used order “Do not resuscitate.” This situation, which is by nature “passive,” must
be clearly distinguished from suicide and euthanasia where a positive act on
the part of the patient or physician is involved.
Normally, it is for the
physician to determine whether a given intervention is extraordinary or not;
appropriate or not. In an earlier time when the family physician was a trusted
friend and family advisor, few problems arose. Today with the
departmentalization of medical services and the resulting depersonalization of
care, such decisions have become more difficult. Nevertheless, such decisions should be made
by physicians and not by theologians, politicians and so-called ethicists. Physicians
should of course involve the patient (whenever possible) and the close family
in such decisions. Can a physician be wrong in his judgment? Physicians are
constantly called upon, by the nature of medical practice, to make judgments
where they can be in error. Certainly this is a possibility. In difficult cases
usual hospital practice often requires that two physicians who have no
connection with the case be asked to make such an evaluation. Very often, when
in doubt, physicians will ask themselves whether the course of recommended
action is one they would wish for a parent or for themselves. Making such
decisions is part of the responsibility of their vocation.
It should not be forgotten
that terminal patients should have the benefit of extreme unction (or if
Protestant or Jewish, the benefit of their minister). While it is preferable
that this occur while the individual is conscious, such services should be
offered “conditionally” if the individual is no longer able to respond. Pius
XII made it quite clear that after these spiritual obligations are fulfilled,
the patient should be given every necessary physical support and made as
comfortable as possible.
Fr. Rama P. Coomaraswamy,
M.D., F.A.C.S.
[1] It should be stressed that adequate hydration like
pain medication is aimed at providing comfort and nothing more.