End-of-Life Choice, Palliative Care and Counseling

Your Final Wish Isn’t Always Your Doctor’s Commandby Blaine

Back

Commentary by Ann Woolner
Bloomberg
December 9, 2009

You think you’ve done the legal paperwork to avoid becoming another Terri Schiavo, who was trapped in a hopeless vegetative state while her family argued over whether to keep her going.

You’ve specified ahead of time that you want nothing artificial to prolong your life, not even a forced-feeding tube, if doctors say you won’t recover from that state.

Don’t rest assured. If that time comes, the documents you labored over won’t count for much if you wind up in the wrong place.

More than 900 hospitals and health-care centers in the U.S. that treated 93 million patients last year are affiliated with the Catholic Church, whose American policy-making body won’t let your end-of-life wishes come true while you are in their care.

Last month the U.S. Conference of Catholic Bishops resolved what had been a debate among clerics and ethicists over the morality of artificially feeding or hydrating patients who are stuck in a vegetative state, possibly for years.

What had been a “presumption” in favor of tube feeding in 2001 became, in the revised policy, an “obligation.”

“This obligation extends to patients in chronic and presumably irreversible conditions (e.g., the ‘persistent vegetative state’) who can reasonably be expected to live indefinitely if given such care,” the bishops announced in the latest version of their Ethical and Religious Directives for Catholic Health Care Services.

If an incapacitated patient has a living will that instructs physicians, it “should always be respected and morally complied with, unless it is contrary to Catholic moral teaching,” the bishops said.

A Big ‘Unless’

 

That’s a big “unless.”

If family members insist that the patient’s directive be followed, they would have to move him to another facility, according to the Reverend Thomas Weinandy, executive director of the Conference of Bishops doctrine committee.

For thousands of Americans, a Catholic hospital is the only one they have, saysCompassion and Choices, a non-profit group that advocates for the terminally ill.

Federal and state laws encourage people to think ahead of time about what medical treatment they would want, and under what circumstances, if they became incapacitated. Hospitals that accept federal funds are required to bring up the subject, and that’s when they advise incoming patients of their policies.

You can spell out your wishes in an advance directive, and you can name a health-care proxy to speak for you on such matters.

Criminal Battery

 

“Where you actually have a medical directive, people are constitutionally entitled to have their wishes given effect,” says Ray Madoff, a law professor at Boston College focusing on end-of-life issues.

The U.S. Supreme Court said so in the Nancy Cruzan case in 1990. But, Madoff asks, who’s going to enforce that right?

Under older case law than Cruzan, if you are given a treatment you specifically declined, it is considered criminal battery under the law. Whether that applies to tubing for food and water, which some see as too basic to human existence to be considered medical treatment, isn’t as clear.

In New York, state law requires an extra level of evidence that the patient didn’t want a feeding tube for it to be denied. An advance directive would accomplish that, and so would a health-care proxy with knowledge of the patient’s wishes.

But I digress.

Larger Issue

 

The conflict between patient and medical personnel speaks to a larger health-care issue that reaches beyond Catholic institutions.

The notion is growing that the institutional or individual conscience of a health professional trumps a patient’s wishes when they conflict, or at least makes them more difficult to carry out.

Health professionals have been winning ever-stronger language in state and federal laws that forbid discrimination against them if their moral or religious beliefs prevent them from assisting or performing abortion or prescribing birth control. You will find some version of it in health-care bills Congress is considering.

And while in most cases of conflict arrangements are made to transfer patients to health-care providers and professionals who will comply with their wishes, that isn’t always possible.

Critical Decisions

 

This tugs at a sacred tenet of American health care: that an informed and competent patient should be allowed to make critical decisions over his own body, even in advance.

Increasingly, the patient’s moral and religious convictions are taking a back seat to the beliefs of people charged with caring for their health.

So it was with the Bishops Conference, which ditched its more ambiguous stance to adopt principles taught by Pope John Paul II.

Catholic hospitals can still follow patient directives that refuse other sorts of medical treatments. The more difficult question was whether food and water are medical treatments and therefore morally optional. And what if the patient could exist for years in a vegetative state?

Or was it something so essential to a person’s humanity that it must be given to affirm the value of human life, indefinitely? Would it be euthanasia to refrain from tubing?

It would, the bishops announced.

“We believe we are upholding the dignity and value of every human life,” Weinandy said in a telephone interview.

And yet, there are others who believe their dignity requires health-care providers to abide by their wishes to keep feeding tubes out of their bodies if they have no hope of ever resuming consciousness.

At a time when the country is in desperate need to reduce health-care costs, surely we could start by agreeing that it’s a good idea for patients not to be given treatment they have specifically refused.