Persons with terminal-but-not-imminent conditions
face problems that presently
outdistance the progress of Church teaching.

Certain death
or life with suffering?

By Thomas A. Reso

The Church has defined specific teachings regarding the rights and obligations to sustain life, even through the use of “extraordinary” means.1 Generally, these teachings address the concerns dealing with those for whom death is imminent or for those who have reached a permanent vegetative state (PVS). For the most part, these are cases that can be resolved with charity and a certain degree of moral confidence, although understandably with difficulty.

But persons with terminal-but-not-imminent conditions2 face situations that generate questions that presently outdistance the progress of Church teaching. While the moral issues accompanying the treatment for those facing imminent death are well defined by the Church, issues regarding the terminal-but-not-imminent are less clear, especially in view of advances in medical science.

What was considered “extraordinary” means during the papacy of Pius XII when he addressed various medical groups in the 1940s and the 1950s3 had become “ordinary” by the 1970s, and what was “experimental” in 1990 is now “routine.” Nevertheless, even a routine procedure can be aggressive and present risks and results that challenge the potential benefits.4

Despite the interval between science and the formulation of moral norms, one can apply to the terminal-but-not-imminent those principles that address the imminently dying.

SITUATION: A cancer patient, after many years of surgeries and treatments, is presented with the choice of electing or refusing major, aggressive surgery. Although the procedures are not experimental, they do hold the possibility of failure and death; if successful, they propose a prolonged and difficult recovery and rehabilitation with resulting incapacities. The procedures can add five, 10 or more years of life. But without them, life expectancy is at best 12 to 18 months, ending in considerable pain and suffering for the patient and loved ones.

Questions and considerations

At first thought, it would appear that one’s self-preservation instinct would compel election for the surgeries.5 But after years of treatments and previous surgeries, it is understandable that a patient will begin to ask when enough is enough, especially when death is foreseen and in fact prepared for, if not longed for. (See Pss. 42, 63 and 84; Isa. 26:9.)

At the least, death could provide avoiding the inevitable years of recovery and rehabilitation, which promise to be difficult in themselves. And for the person of faith, death presents an escape from this world and all its sufferings and deliverance to eternal peace and happiness. (See Pss. 6, 17, 22, 30, 88.)

If the reason for refusing to have the surgeries were to die sooner rather than later so he can go to heaven, is this an end pursued by the wrong means? Although there is no guarantee of success, the procedures have a history of prolonging life, which could include the prospect of dying later from some other illness. But does one have the right to choose the time and circumstances of one’s death, even under such conditions?

While the strains of a prolonged and very difficult recovery, diminished capacity, and deterioration of quality of life offer little attraction, they must be evaluated in light of the almost-guaranteed sufferings to result by refusing the procedures. In either case, is poor quality of life better than no life, even when the object pursued is eternal life?

The patient also has to consider what effects the decision would have on loved ones, regardless of the choice.

Refusal of the procedures presents to the patient the prospect of preparing and living with loved ones who would know he has made this choice. While the shock of death does not discriminate between sudden and foreseen circumstances, one has to be mindful of the spiritual and psychological effects imposed on loved ones who would just as soon forestall their emotions as long as possible.

It might indeed be easier for loved ones to accept ending nutrition and hydration had the patient progressed to a PVS as opposed to his consciously refusing procedures that offer a promise of prolonging his life, even though under a considerable accompanying ordeal.

Accepting the procedures is not without impact on loved ones, since it is they who will also endure, even if sympathetically, the struggles of recovery and rehabilitation. There is also the consideration that must be given to cost and extra burdens placed on loved ones by electing the procedures.

Similarly, the patient must consider the burden he could possibly be with or without the procedures:
Without the procedures there is the near guarantee of an end with pain, suffering and loss of dignity, cared for and endured by family and friends.

With the procedures there is the extended recovery and rehabilitation (if the procedures are successful) that are certain to produce strain and anxiety; and even so, there is the prospect that a painful death might just be postponed. In this case there would be the experience of both a prolonged recovery and a difficult death, also to be suffered by loved ones.

Deliberations and answers

Choice of one’s time and conditions of death does not belong to the individual, even when the provocation is to attain eternal life in heaven.6

“Human life is at once a gift and a responsibility—a gift, because man could never create himself; a responsibility because man must use this gift properly. God, life itself, is the source of all other life and to Him alone, therefore, belongs every power over it.”7 As St. Paul wrote, “None of us lives as his own master, and none of us dies as his own master. While we live we are responsible to the Lord, and when we die we die as his servants. Both in life and in death we are the Lord’s” (Rom. 14:7-8).

Regarding the issue of “quality of life,” the U.S. Bishops’ Committee for Pro-Life Activities stated in 1986, “Because human life has inherent value and dignity regardless of its condition, every patient should be provided with measures which can effectively preserve life without involving too grave a burden.”8 Although this applies directly to those for whom death is imminent and who may have reached a PVS, it has further implications for those who are terminal but not facing imminent death.

The phrase “without involving too grave a burden” poses a qualifying distinction. Ultimately, one has to evaluate whether the measures to prolong life present burdens which outweigh the potential and desired outcome.9 In making a moral decision, procedures that offer burdens that might be disproportionate to the results that can be obtained must be evaluated in light of the “reasonable hope of benefit,” the “common or usual use” of the procedures, the proportion to “one’s status” (including one’s financial condition), the “difficulty” of the procedure, and the “reasonableness” for the person in his circumstance.10

Ultimately, since “there is [sic] no absolute norms which would render some means as always ordinary, the norms are relative to the individual person in his particular circumstances.”11

The benefit-to-burden measure must also be applied to the impact on family and friends, in due consideration to one’s circumstances. Financial strain on family is a legitimate consideration, especially if this means that funds expended on behalf of the individual in question would deprive another in the family of the fundamentals of living. Since this is not the situation in the case under discussion, the argument left to consider at this point is the psychological and sympathetic sufferings of loved ones.
While elimination of all pain from loved ones is desired, one could hope that his individual suffering could be of benefit to his network of relationships and to society in general. For the individual, such suffering can be a source of consolation, character and hope (see Rom. 5:3-5), and the residuals of suffering can extend beneficially to others. (See in sequence Isa. 52:13-15; 53:1-6; Matt. 8:16-17; John 1:29; Col. 1:24; 1 Pet. 4:13.)

“Suffering, while still an evil and a trial in itself, can always become a source of good. It becomes such if it is experienced for love and with love through sharing, by God’s gracious gift and one’s own personal and free choice, in the suffering of Christ Crucified.”12

“When this body is gravely ill, totally incapacitated, and the person is almost incapable of living and acting, all the more do interior maturity and spiritual greatness become evident, constituting a touching lesson to those who are healthy and normal.”13
The individual’s suffering can contribute to the redemptive suffering of Christ, for “Those who share in the sufferings of Christ preserve in their own sufferings a very special particle of the infinite treasure of the world’s redemption and can share in this treasure with others.”14

And further, “the offering of their sufferings may hasten the fulfillment of the prayer of the Savior himself that all may be one.”15
Decision

On balance, and applying the principles that pertain directly to those for whom death is imminent, the terminal patient elects to choose the aggressive surgeries and the prolonged recovery, even considering the diminished physical capacity and the other burdens attached.

The reasonable hope for extended life is strong, and the burdens are not unmanageable, although extreme. There is the benefit to society that the experience can perhaps further medical science; and there is also the opportunity to serve as an example—a witness—to those who experience the ordeal with the patient. Further, the prospect to offer his suffering for others and to share in the ongoing work of Christ’s redemption16 is a unique and sufficient argument in itself that outweighs the associated burdens.
The morality of the decision is based on the strong foundations of moral law, the Judaeo-Christian ethic, Sacred Scripture, Church Tradition and Church Teaching. It is supported by the measure of benefits to burdens: the benefits are durable and far reaching, while the burdens are resolved by the patient to be “inconveniences.”

In the end, the prospect of deriving an overwhelming good in the process more than tips the balance of the moral scale. Refusing the procedures tips that scale below the individual’s measure of what his conscience considers moral.

1 For a historical survey of the Church’s discussions on preserving life by ordinary and extraordinary means, see “Conserving Human Life,” A Doctrinal Dissertation by Bishop Daniel A. Cronin (1958), contained in Conserving Human Life, Part I (Pope John XXIII Medical-Moral Research and Education Center, Braintree, Massachusetts, 1989), Russell E. Smith, S.T.D., ed.
2 Msgr. Orville N. Griese, S.T.D., J.C.D., “Feeding the Hopeless and the Helpless,” Conserving Human Life, Part II, Op. Cit., p. 185.
3 Cronin, p. 156.
4 Cronin, pp. 84-85.
5 Thomas Aquinas, Summa Theologica, II-II, Q 25, Art. 4 & 5.
6 ST, II-II, Q 64, Art. 5, 3. See also Matt. 24:36; 25:13; Mark 13:32.
7 Cronin, p. 3.
8 Griese, p. 177.
9 Albert S. Moraczewski, O.P., Ph. D., “The Moral Option Not to Conserve Life Under Certain Conditions,” Conserving Human Life, Part III Op. Cit., p. 235.
10 Ibid., pp. 254-261. See also Cronin, Ibid., pp. 88-111.
11 Moraczewski, p. 261. See also “Pastoral Concerns, Ethics Committees in Catholic Health Care Facilities,” Panel with Msgr. James P. Cassidy, Ph. D., and Kevin D. O’Rourke, O.P., J.C.D., S.T.M., Critical Issues in Contemporary Health Care, Proceedings of the Eighth Bishops’ Workshop, Dallas, Texas, 1989 (Pope John XXIII Medical-Moral Research and Education Center, Braintree, Massachusetts, 1989), Russell E. Smith, S.T.D., ed., p. 171.
12 John Paul II, Evangelium Vitae (The Gospel of Life), The Encyclical Letter on Abortion, Euthanasia, and the Death Penalty in Today’s World (Times Books, A Division of Random House, New York, New York, 1995), p. 123.
13 John Paul II, Salvifici Doloris (On the Christian Meaning of Human Suffering), Apostolic Letter (United States Catholic Conference, Washington, D.C., 1984), p. 31.
14 Ibid., p. 34.
15 Ibid., p. 40.
16 Ibid., pp. 24-29.

Mr. Thomas A. Reso is an accredited counselor in public relations and is a catechist at St. Joseph Parish in Ponchatoula, La. (diocese of Baton Rogue). He holds a B.A. degree in English literature, and he has completed courses of study at the diocese’s Religious Study Institute. In 1992 he was first diagnosed with a rare form of head and neck cancer. Since that time he has undergone more than 100 hours of surgery through fourteen procedures.

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