End-of-Life Choice, Death with Dignity, Palliative Care and Counseling

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Pope vs. Doctors: How New Vatican Orthodoxy Undermines Medical Ethics and Imperils Your Health

 Jacob M. Appel, Bioethicist and medical historian

The Huffington Post

Posted: February 10, 2010 05:31 PM

Catholic hospitals, which boast a long and admirable history of caring for the seriously ill and indigent in the United States, have for many years finessed the challenges of serving two disparate and often incompatible masters. On the one hand, the nation’s 573 Church-run hospitals and their physicians are not permitted by Vatican policy to offer services or advice to patients when doing so violates Catholic teaching. In theory, prohibited activities range from providing abortions and assisting suicides to urging patients with HIV to wear condoms when engaged in unprotected sex or telling bipolar women on lithium to use contraceptives to prevent birth defects. On the other hand, these hospitals–which serve about one third of all patients in the nation–are also quasi-public institutions, and their physicians and nurses are bound by the same ethical obligations that govern all other members of their professions. They must obtained informed consent, honor patient autonomy, and offer medical care in line with the clinical standards of their colleagues at secular institutions. While a latent tension often exists between these competing allegiances, two recent developments relating to Church policy have set medical ethics and Catholic doctrine on an unfortunate collision course.

The first of these disturbing Church salvos against mainstream medical ethics is to be found in the newly promulgated Directive 58 of the United States bishops’ body governing Catholic health care services. This edict states that, barring certain specific circumstances, such as imminent death, Church doctrine prevents competent patients from refusing artificial nutrition and hydration. William Grogan, a religious advisor to Cardinal Francis George of Chicago, explained to the media that death would have to be expected within two weeks for a patient to turn down a feeding tube. In other words, according to current Catholic teaching, a cancer patient in a coma with a life expectancy of four weeks must now be force-fed–no matter what his prior instructions stated and without regard to his family’s wishes. All comatose and vegetative patients will be required to accept nutrition and hydration indefinitely, even if they leave behind air-tight living wills objecting to such “heroic” and invasive measures. This extreme policy apparently applies to all patients receiving care in Catholic-run hospitals, whether or not they are Catholic. Since United States courts have consistently accepted that mentally-competent patients have a right to refuse care if their wishes are clear and documented, these rules may well be illegal. However, even if Directive 58 is not a violation of the law, it is a gross breach of accepted standards of medical ethics. No doctor or nurse in the United States may provide such unwanted nutrition and hydration without defying a well-established code of professional conduct. It is likely that any provider who acted in this paternalistic and unequivocally immoral manner would lose his or her license. In the very least, the provider would become a pariah among his colleagues.

A second Church-instigated challenge to medical ethics has arisen as a result of a grass roots protest by anti-abortion organizations in Pennsylvania against the well-regarded St. Mary’s Medical Center of Langhorne. In this case, Dr. Stephen Smith of St. Mary’s performed an ultrasound on an expecting mother and confirmed that the fetus had polycystic kidney disease, a fatal condition in infants. Smith recommended an abortion. When the pregnant women sought a second opinion, a midwife at Mother Bachman Maternity Center in nearby Bensalem, operated by the St. Mary’s, also recommended termination. The mother refused, which was certainly her prerogative, and the infant died two hours after birth. When local abortion opponents publicized Smith’s advice, a private citizen named Joseph Trevington demanded a formal review of St. Mary’s by the local archdiocese. The results of this ethics investigation are not yet publicly known, and may never be revealed, although a diocese spokesman stated that changes in the hospital policies are to be expected.

The very decision to conduct such a moral audit displays a chilling new direction in Church practice. As a matter of doctrine, Catholic hospitals require employees to “respect and uphold the religious mission” of their institutions as “a condition for medical privileges and employment.” So, in theory, any physician endorsing abortion (or vasectomies, birth control, withdrawal of life support, etc.) while on the hospital premises should be relieved of his duties. As a matter of Catholic doctrine, Trevington and his anti-abortion brethren appear to have the better half of the theological argument, at least when it comes to consistency and the letter of the law. At the same time, allowing Church dogma to dictate the medical practices of physicians clearly violates the most basic tenets of healthcare ethics. Dr. Smith had a duty to offer advice to his patient based upon his best independent professional judgment–which he apparently did. The Hobson’s choice that he faced–either to follow the Catholic “law” enshrined as policy or to adhere to medical obligation–was unreasonable and unacceptable.

Both of these events expose the dark and unspoken (although widely understood) secret that enables Catholic hospitals to practice first-class medicine: Official Church policy on matters such as contraception and end-of-life care, like much Catholic doctrine more generally, is largely honored only in the breach. I have known many excellent physicians over the years, both religious and secular, who work at Church-run hospitals. All of them advise women taking medications that cause birth defects to use contraception and tell HIV-infected patients to use condoms. Many offer direct counseling on abortion, certainly when fetal prognosis is grim. I cannot imagine any of these gifted doctors would force-feed an unwilling cancer patient in violation of an advance directive or a health care proxy’s wishes. Much like the absurd loyalty oath that New York’s college professors–myself included–take to uphold the state’s constitution, any pledge to support Catholic doctrine on medical matters is broadly viewed as a formality to be agreed to and then summarily ignored. Historically, the Church has looked the other way. Now, by challenging this longstanding system of benign neglect, bishops and grass roots zealots may believe they will achieve ideological purity. What they are actually doing is jeopardizing both the welfare of Catholic hospitals and the public health.

Some concrete thinkers may argue that since Catholic hospitals are “private” institutions, the Vatican can impose any rules that it wants. The claim belies the inherently public nature of the American hospital system. Catholic hospitals–like virtually all other hospitals in the Unites States–are only able to function as a result of a swath of government handouts and subsidies. Medicare and Medicaid pay the bills of almost half their patients. Federal funding supports the salaries of their medical residents. NIH Grants sponsor their research and clinical care. Many of the hospital buildings themselves were erected will federal construction dollars providing by the Hill-Burton Act of 1946. Private businesses may have a claim to considerable leeway in formulating their own rules and policies–although even “mom & pop” stores are reasonably prevented from excluding African-American customers and are often required to accommodate disabled shoppers. In theological matters, the Pope is certainly free to issue any decree he likes and those who wish to follow his dictates are entitled to do so. In contrast, Catholic hospitals function as public entities that serve people of all faiths and traditions. A patient in a medical emergency is taken by ambulance to the nearest hospital, not the nearest hospital that shares his social values. A system that operated otherwise would lead to logistical chaos and increased mortality. Once one accepts the premise that Catholic hospitals are public institutions, they have a moral obligation to comply with generally accepted standards of patient care and professional ethics. Today’s hospitals are far more Caesar’s than they are God’s.

One of the greatest triumphs of modern health care in the United States is the rise of nonsectarian service. In an earlier era in New York City, for example, Jews sought care at Mount Sinai while Protestants preferred Presbyterian Hospital and Catholics chose St. Vincent’s. Now, most patients–and all wise ones–choose their health care providers for clinical skills and personal attributes, not religious labels. As a result, the majority of patients at Catholic hospitals are not Catholic. To impose orthodox Catholic doctrine on these non-Catholic individuals at the most vulnerable moments of their lives would be the most significant Church intervention in the lives of non-adherents since the Inquisition. Doing so would also threaten the ability of physicians to practice at Catholic hospitals without violating their professional codes of ethics. In light of these developments, any patient currently receiving care in a Catholic-run hospital should immediately clarify with her doctor whether this physician will follow the patient’s own end-of-life wishes regarding so-called heroic measures if they come into conflict with Directive 58.

The Catholic Church has every right to announce and publicize its views on certain medical interventions and to declare that Catholics who engage in certain conduct are violating the rules of the Church. It’s the Pope’s club. He can make the by-laws. He does not have any business imposing such rules on third parties who do not wish to follow them. It will be a sorry day if American patients seeking the best medical care are forced to avoid Catholic hospitals for fear of having their living wills ignored or their doctors’ counsel dictated from Rome. The Church would be wise to focus its energies on theology and to leave the practice of medicine to the professionals.

Read this post at its original site at The Huffington Post.

Catholic Hospitals Will Have to Comply with the Bishops Rules

Will Not Honor Conflicting Advanced Directives

On November 17, 2009, with little fanfare, the United States Conference of Catholic Bishops issued a directive for Catholic health care that could bring distress and grief to hundreds of thousands of American families each year. The directive is binding on all Catholic hospitals, hospices and nursing homes. It forbids removal of artificial food and hydration tubes from a patient in any Catholic health care setting, regardless of patients’ expressed wishes as contained in an Advance Directive or similar document. 

This directive limits your healthcare choices.

Questions have arisen about how a church hierarchy can abrogate legal directives from patients and whether Catholic health care providers will be required to follow church directives, whether patients are Catholic or not.

Below please find excerpts from some relevant directives:

Ethical and Religious Directives for Catholic Health Care Services (Emphasis added)

5. Catholic health care services must adopt these Directives as policy, require adherence to them with the institution as a condition for medical privileges and employment, and provide appropriate instruction regarding the Directives for administration, medical and nursing staff, and other personnel.

8. …the relevant requirements of canon law will be observed with regard to…

68. …must respect church teaching…

24. … The institution, however, will not honor an advance directive that is contrary to Catholic teaching.

28. … The free and informed health care decision of the person or the person’s surrogate is to be followed so long as it does not contradict Catholic principles.

59. … life-sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching.

It appears that the Directives: (1) limit a patient from electing aggressive pain care, including terminal sedation-an accepted practice in medicine, ethics, and law; (2) result in the disregard of advance directives or decisions made by a health care proxy; and (3) result in the application of unwanted life support or the continuation of unwanted life support.

Read the Ethical and Religious Directives for Catholic Health Care Services here>>

Your Final Wish Isn’t Always Your Doctor’s Command

Commentary by Ann Woolner
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.

Catholic Bishops Lay Down the Law on Feeding Tubes

On November 17, 2009, with little fanfare, the United States Conference of Catholic Bishops issued a directive for Catholic health care that could bring distress and grief to hundreds of thousands of American families each year. Compassion & Choices wants you to know how this limits your healthcare choices.

“This won’t affect my family,” you may say to yourself. “We aren’t even Catholic.”

That doesn’t matter. Approximately 30% of Americans receive healthcare or reside in Catholic institutions, and this edict could affect any of them.

A little known but far reaching aspect of the Church’s organizational structure requires every hospital, nursing home, assisted living center, etc., with a Catholic charter to abide by a set of rules called “Ethical and Religious Directives for Catholic Health Care Services.” The 72 directives itemize exactly how the services you receive will conform to Catholic doctrine, as promulgated by the Holy See and enforced by its Congregation for the Doctrine of the Faith (formerly known as the Holy Office of the Inquisition.)

The Bishops’ latest change to Directive #58 says everyone who needs a feeding tube to stay alive must have one surgically implanted, and must keep it indefinitely. This will apply to anyone in a permanent coma from stroke or trauma, in persistent vegetative state or with advanced dementia, having lost the ability to eat along with other sentient activity. It will apply irrespective of your religious faith, your stated wishes in an advance directive, or the instructions of your family.

The Catholic Healthcare Association was quick to point out the new Directive does not apply to patients who are actively dying. But those are not the usual recipients of feeding tubes anyway. Rest assured, it applies in all situations where we most cherish our own authority to make healthcare decisions.

Catholic hospitals probably hoped this day would never come. The Bishops put them in a real bind. Ever since Pope Benedict XVI (Formerly Joseph Cardinal Ratzinger, Prefect of the Congregation for the Doctrine of the Faith) articulated this rule during the Terri Schiavo fiasco, hospital spokespeople have held tenaciously to a balancing rationale that allowed them to honor a person’s stated wishes in these matters. Last month the Bishops pointedly dismissed the “untenable positions” of “some Catholic ethicists” and made Benedict’s strict rule official and binding. Now hospitals and nursing homes have no choice but to enforce Catholic doctrine universally over patient wishes.

What had been Directive #58’s “presumption” in favor of feeding tubes is now an “obligation” and the language about balancing is gone. Pity the poor hospital administrators. As much as they may wish to honor the advance directives of patients and the heartfelt decisions of grieving families, the Church just won’t let them do that anymore.

I know a lot of readers are incredulous. “Surely,” you think, “no sane church would force hundreds of hospitals to systematically trump established principles of patient autonomy and force disruption, adversity and grief on families.” It seems unfeeling, unethical, and hardly good for business.

Well, think again, for when it comes to settled dogma, this church does not compromise.

Let me describe a precedent, and a clue to what lies ahead for families: For decades Catholic hospitals have subjected new mothers to unnecessary inconvenience, pain and surgical risk to enforce Directive #53, which forbids sterilization. Every doctor knows the safest, most convenient time to perform an elective tubal ligation is immediately following delivery of a baby. The uterus is high and fallopian tubes readily accessible. Yet women delivering in Catholic centers who request this simple operation must recover from delivery, then submit to a second hospitalization, a second anesthetic and surgical risk and the pain of a second procedure, at a non-Catholic institution. Not to mention the cost of the second operation, routinely borne either by insurers or tax payers — that is to say, all of us.

From the Bishops’ perspective, this is a small price to pay to maintain what they call “the distinctive Catholic identity of the Church’s …health care ministry.” Central to that ministry is imposition of the Church’s “moral teaching” on all its patients.

Many of us view Catholic hierarchy as having long ago squandered any moral authority they might once have had. Church officials cannot engage in conspiracies to hide crimes of sexual molestation and protect child abusers on one hand, and on the other, presume to dictate legitimate healthcare decisions. Certainly they have no authority over decisions as central to personal dignity as whether I will accept or reject medical feeding to keep my comatose body alive. The sanctimonious audacity of these Bishops simply takes my breath away.

Catholic Bishops Enact Plan For 300,000 Terri Schiavos

By David Dayen
November 24, 2009

The US Conference of Catholic Bishops released an “Ethical and Religious Directive” this month that would ban any Catholic hospital, nursing home or hospice program from removing feeding tubes or ending palliative procedures of any kind, even when the individual has an advance directive to guide their end-of-life care. The Bishops’ directive even notes that patient suffering is redemptive and brings the individual closer to Christ.

The Catholic bishops have become more involved in political fights in recent years, particularly the issue of abortion coverage and immigration provisions in the current health care debate. This has caused a schism in the American Catholic community, which bubbled to a head yesterday with Rep. Patrick Kennedy (D-RI) being denied communion because of his position on choice.

More quietly, however, the Church has staked out a radical position on end-of-life care, without patients of the 565 Catholic hospitals and other Catholic care facilities even knowing about it. As Barbara Coombs Lee, president of Compassion and Choices, an advocacy group, put it, “When a patient goes to one of these facilities, they don’t know that they’re choosing Catholic dogma. The bishops see the hospitals as an extension of their ministry.”

The “Ethical and Religious Directives for Catholic Health Care Services” put out by the Catholic bishops would build upon a Papal elocution given in the wake of the controversial Terri Schiavo case, where the US Congress stepped in to keep Schiavo alive despite her persistent vegetative state and the wishes of her husband to end care. The papal elocution did state that the permanently unconscious should always have access to a feeding tube, but it did not have the force of doctrinal law behind it. “There was always some wiggle room” for Catholic care facilities, said Coombs Lee. Catholics were allowed to use something called a “benefit/burden balance” to determine the ethical, moral and compassionate result in any individual case.

Now, that wiggle room is gone. In the new directive, the bishops state that it is unethical and immoral to withhold or withdraw a feeding tube from patients, whether in cases of permanent unconsciousness, comas, or even cases of advanced dementia when the patient is unable to feed themselves.

This substitutes the wishes of the bishops for the stated wishes of families and the patients themselves, said Coombs Lee. Even if the family can produce an advance directive or living will, Catholic hospitals and nursing homes would be expected to maintain the feeding tubes. In addition, all Catholic health care workers are required by their faith to continue palliative care, according to the document. The directive even addresses patients. “These are directives for you, from the church,” said Coombs Lee.

In many cities, this means that every hospital or medical care facility will not allow the withdrawal of a feeding tube. “In Spokane, Washington, if you don’t get Catholic health care, you don’t get health care,” Coombs Lee said. “In Eugene, Oregon, if you don’t get Catholic health care, you don’t get health care.” Coombs Lee characterized it as a kind of entrapment, with a sense of “my house, my rules.” If a patient’s family wanted to comply with an advance directive, they would have to leave the Catholic care facility, adding a level of stress and disruption to the already difficult time of aggrievement. “Decisions on feeding tubes are hard enough without adding this extra adversity,” said Coombs Lee. Coombs Lee believes that this could create “300,000 Terri Schiavo cases,” the number being equal to the number of feeding tubes inserted in the United States each year.

The Catholic Hospital Association disagrees. Their statement responding to the Bishops’ Ethical and Religious Directive says that:

However, the Directive explains that this obligation ceases and the measures become “morally optional” when the measures cannot reasonably be expected to prolong the patient’s life or when they become excessively burdensome. (This provision incorporates into the Directive the teaching of Pope John Paul II and the Congregation for the Doctrine of the Faith regarding medically assisted nutrition and hydration to persons in a persistent vegetative state. Catholic health care facilities have already addressed the implications of these statements).

The Directive also distinguishes between patients in a chronic state and those who are dying. This distinction has implications for the use of medically administered nutrition and hydration. For dying patients, medically administered nutrition and hydration may no longer be of benefit and may, in fact, impose significant burdens.

Compassion & Choices says that this language distinguishing between those cases where artificial nutrition is “excessively burdensome” appears nowhere in the Bishops’ directive. Furthermore, while the CHA says the directive only applies to those patients being kept alive by a feeding tube, that is precisely their function. As Coombs Lee puts it, “Feeding tubes keep people in chronic states like PVS and advanced dementia alive… Feeding tubes are not indicated for people actively dying and they are rarely inserted in any institution, Catholic or not.”

A 60Minutes piece this weekend looked at the cost of dying in America, showing that Medicare paid $50 billion in the last two months of patients’ lives in 2008. Compassion & Choices focuses on the suffering at the end of life, not federal dollars, but they agree in general with the portrait shown by 60 Minutes. Incredibly, suffering is one of the selling points in the Catholic Bishops’ directive. “It’s quite specific about the role of suffering in Christian dogma,” Coombs Lee explained. “It says that suffering is redemptive, that it’s part of Christ’s passion. So they are pretty clear on their concern for the suffering of the patient.”

The end of life issue became very controversial in the health care debate, over fears that Congress was creating so-called “death panels.” However, these secret “suffering panels” put in by Catholic hospitals are being done without much fanfare at all. “People need to know,” said Coombs Lee, “when they commit themselves to a hospital, that they are submitting to a Catholic ministry, in the eyes of the Bishops.”