Saturday, January 23, 2010

End-of-Life Ethics Question

This was originally posted in response to a question raised by a listener on a radio broadcast of the show Sound Rezn. Follow this link to the show's blog where my original response was posted:

QUESTION: Just started listening to today’s program. I always appreciate the Biblical teaching you bring when I am able to listen. On today’s topic, I need more information, Biblical council concerning caring for elderly parents. I wonder how much medical assistance, prescription drugs, etc.,we should pursue when trying to provide care. My father is in a nursing home. He is unable to do anything without assistance. He has a feeding tube because he lost the ability to swallow last spring and he made the decision to have the tube put in. Today he is barely able to talk or carry on a conversation. His sight is almost gone. He yells “help” day and night. Sometimes he needs help. Usually, he simply wants someone by his side so that he is not confused about the activity around him or in the hallway. Sometimes he really needs help. It has been suggested to increase a drug that he is currently using which would probably cause him not to yell so much, but probably sleep more. I do not know how to make these decisions. Watching both my parents suffer with Alzheimer’s disease, I wonder what we are doing by adding another drug to keep them going. My heart aches with this ethical question wanting to be obedient to God and to honor my father and mother as we are commanded to do. This is only a small portion of the situation. I know my family is not the only one struggling with elderly parents. I would appreciate any council you may offer. Most of all, I am asking for prayer. Our Father in heaven is not a god of confusion. But, at times, I ache with confusion.

REPLY: It is no easy thing to watch a loved one deteriorate when there is no perceivable hope of recovery. That’s why cases like these can be so hard to decide. This case also exemplifies how technological advances in medicine, while many in their benefits, also bring with them burdens. Fortunately, traditional medical ethics, informed by the Hippocratic and Christian traditions, provides us with important distinctions that are helpful in guiding our way through the maze of these kinds of hard cases.

The oldest of these is the Hippocratic tradition. This tradition maintains that the primary duty of the physician is to do no harm. This precludes the administration of poisons in order to prematurely end the lives of patients. The Hippocratic ethos conceives the primary practice of medicine as the relief of suffering wrought by disease. When medicine can no longer accomplish this end, the physician and patient ought to recognize the futility of medicine and withdraw or withhold its use. Thus, this tradition asserts that the purpose of medicine is to relieve suffering associated with sickness and disease and that when medicine can no longer achieve this goal, the physician should no longer employ medicine. (The exception here is comfort care. This should always be prescribed.) The implication is that the extension of medicine beyond its purpose could potentially cause greater harm to patients in hopeless medical conditions.

In conjunction with the Hippocratic tradition, traditional Christian medical ethics draws out two important distinctions that remain well embedded in American law and ethics. While recognizing an obligation to heal, there exists no moral obligation to extend life at all costs. The traditional means for determining whether care is beneficial is found in the distinction between ordinary and extraordinary care. Ordinary care refers to any treatment modality that has reasonable benefit for the patient, as determined by the patient. According to the Christian moral tradition, foregoing these sorts of treatments is morally prohibited. Extraordinary care refers to any treatment modality that does not provide reasonable benefit to the patient, as determined by the patient. In other words, the treatment is overly burdensome and benefits the patient little, if at all. These sorts of treatments may be foregone.

There is also the distinction between killing and allowing to die. While the Christian tradition prohibits the direct killing of an innocent human person, allowing someone to die is sometimes morally permissible. For instance, a patient may decide not to employ certain medical treatments to prolong his or her life. Withholding such treatment, if the treatment is deemed extraordinary by the patient, is morally acceptable even though it will result in the death of the patient. In another case a patient may decide to stop a medical treatment or procedure that has already begun. In cases of this sort, withdrawing treatment is considered morally permissible if such treatment is considered extraordinary by the patient. Finally, when the administration of pain medication contributes to a patient’s death, the general consensus is that in such cases the intention to relieve pain qualifies the act as an indirect cause or a hastening of death (by use of the principle of double effect).. In these cases it is the underlying condition that is considered the direct cause of death. When the wishes of a patient are unknown, then a surrogate should decide based on either the substituted judgment standard (in which case the surrogate decides by virtue of his or her personal knowledge of the patient) or the best-interest standard (what is in this patient’s best interest).

The application of these distinctions to this case indicates that the best course of action is to accept the increase of the drug as an effort to make your father more comfortable. Clearly his diminished condition is causing him distress, which is only going to get worse as time goes on. When it is clear that a patient is dying, is unaware, and cannot improve, it is appropriate to consider limiting life-extending treatment. But that is different than extending care to ease suffering. It’s not clear that the administration of the drug will needlessly prolong his suffering. Rather, it sounds like a comfort care measure that ought to be given.

Another related issue concerns the continued administration of the feeding tube that your father initiated. It is possible that in the course of discussing options with his health care providers, the suggestion of withdrawing the feeding tube may come up as his condition deteriorates.. This could potentially complicate matters. There is considerable debate among Christian ethicists concerning the appropriateness of withdrawing nutrition and hydration. Some argue that it should be considered ordinary care under all circumstances, while others might consider it extraordinary under certain conditions, such as when a patient enters a state of severe diminished conscious capacity (e.g., patients in a permanent vegetative state). These are hard cases, especially when a patient has failed to make his or her wishes known ahead of time. My recommendation is that you should seek means to ensure that your father is as comfortable as possible in his final days, and since his condition does not fall into a category in which the tube might be considered overly burdensome (extraordinary), the feeding tube should not be removed.

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