Brief: Patient Dignity and Physician Conscience
January 26, 2019
A Catholic perspective:
The foundational Catholic principle of respecting the inherent dignity of human life from conception to natural death is at the heart of our call for access to ethically responsible healthcare. Saint John Paul II emphasized the clear right to life in his encyclical, Evangelium Vitae, in which he further articulated and responded to the modern threats to the sanctity of human life at all its stages. He affirmed that the sanctity of human life is clear and present in every human being, regardless of age, stage, or disability. In this sense, all human life has inherent quality by virtue its of humanity. [1] Through the Declaration on Euthanasia, the Congregation for the Doctrine of the Faith clearly defines and rejects euthanasia under any and all circumstances as inherently evil because it is the direct willing of death. [2]
In a report to the Pontifical Academy for Life, Cardinal Elio Sgreccia points out that the consequences of the concept of judging a patient’s quality of life have led to “the overwhelming desire to eliminate the concepts of disease, pain and death.”[3] As Catholics discern end-of-life care, it is critical that we view our decisions through this lens of the inherent sanctity of human life, including life in its final stages, as a life that is coming to its physical end on this Earth. Thus the Catholic Church rejects medical decision making based on the flawed “quality of life” arguments as these are often used to falsely justify euthanasia.
Catholic moral and ethical teaching does not support the concept of radical autonomy; instead, it highlights a balance between personal and professional autonomy and common good. The Church recognizes the professional competency of physicians to make judgments regarding whether or not treatment is disproportionate to the foreseen result as they assess the quality and effectiveness of the therapeutic intervention, including whether or not CPR is appropriate in a given case. While the “reasonable wishes of the patient and patient’s family” should be respected, the Church also teaches that there are in fact limits on the autonomy of the patient and his family when their requests are unreasonable. Physicians are bound by a sacred oath because they have the science, the art, the competency and the ability to make these kinds of judgments.[4] At the same time, they are not infallible and the ethics committee review process in Texas law provides checks and balances for their decision making in order to ensure the protection of the life and dignity of the patient, including respect for his reasonable autonomy.
Cardinal Sgreccia explains, “The patient’s conscience cannot be violated by the physician, nor can the physician’s be forced by the patient: both are responsible for life and health as both are personal and social goods.”[5] Saint John Paul II explicitly warned against views of freedom that promote absolute autonomy as serious distortions of life in society. He pointed out that this type of promotion of self inevitably leads to the point of rejecting the autonomy of others such that, “everyone is considered an enemy from whom one has to defend oneself.”[6] This attitude is evident in the analysis that implies that medical professionals seek to manipulate families and euthanatize patients simply because they counsel against ineffective medical interventions.
Some medical interventions are actually harmful to the human person and therefore constitute violence to the human body. Archbishop Jose Gomez refers to this aggressive medical treatment at therapeutic tyranny[7] and Saint John Paul II said that inappropriate medical intervention on dying patients can be “particularly exhausting and painful for the patient, condemning him in fact to an artificially prolonged agony.”[8]
Forcing health care workers to administer these interventions by law, requires them to violate the dignity of the human person. Imposing indefinite treatment on dying patients ignores the professional judgment of the physician and violates the principle of totality and integrity. This leads to conditions such as moral distress in which the healthcare provider knows the correct ethical and moral action, but is prevented from taking it or is required to take an action he or she believes to be immoral and unethical.[9] Several states, in addition to Texas, recognize the autonomy of physicians by providing legal protection for them when they refuse to provide medical interventions that they believe to be unethical or harmful.
Prudence requires conscience formation and a genuine attempt to understand and accept the teaching and recommendation of the Magisterium of the Church. The Catechism notes:
As far as possible conscience should take account of the good of all, as expressed in the moral law, natural and revealed, and consequently in the law of the Church and in the authoritative teaching of the Magisterium on moral questions. Personal conscience and reason should not be set in opposition to the moral law or the Magisterium of the Church.[10]
Our faith and indeed our human nature calls us to always protect life—to protect the human person as an integration of physical body and spiritual and rational soul. The Church teaches, “today, it is very important to protect, at the moment of death, both the dignity of the human person and the Christian concept of life, against a technological attitude that threatens to become an abuse.”[11] This respect recognizes that the life of our body comes to an end as our spiritual life continues toward our final end of union with God in heaven.
The Texas Catholic Conference of Bishops has an end-0f-life care conscience formation guide that further outlines these principles.[12]
[1] Pope John Paul II, Encyclical on The Gospel of Life, Evangelium Vitae, (25 March 1995).
[2] Congregation for the Doctrine of Faith. Declaration on Euthanasia, (5 May 1980). At The Holy See, http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19800505_euthanasia_en.html
[3] Elio Cardinal Sgreccia, Report on the occasion of the General Assembly of the Pontifical Academy For Life: "Quality of Life and the Ethics of Health" (21-23 February 2005). At The Holy See, www.vatican.va/roman_curia/pontifical_academies/acdlife/documents/rc_pont-acd_life_doc_20050223_report-health_en.html
[4] Declaration on Euthanasia, IV states, “But for such a decision to be made, account will have to be taken of the reasonable wishes of the patient and the patient's family, as also of the advice of the doctors who are specially competent in the matter. The latter may in particular judge that the investment in instruments and personnel is disproportionate to the results foreseen; they may also judge that the techniques applied impose on the patient strain or suffering out of proportion with the benefits which he or she may gain from such techniques.”
[5] Sgreccia, Personalist Bioethics, p. 180.
[6] Evangelium Vitae, no. 20
[7] Most Reverend Jose H. Gomez. A Catholic Bishop Responds…A Will to Live: Clear Answers on End-of-life Issues. Irving, Texas: Basilica Press, 2006.
[8] Saint John Paul II. “To Participants at the International Congress on Assistance to the Dying.” L’ Osservatore Romano, n. 4 (18 March 1992).
[9] Elizabeth G. Epstein and Sarah Delgado, "Understanding and Addressing Moral Distress" OJIN: The Online Journal of Issues in Nursing (Sept 30, 2010) Vol. 15, No. 3, Manuscript 1. At http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Courage-and-Distress-/Understanding-Moral-Distress.html
[10] Catechism of the Catholic Church, no. 2040
[11] CDF, Iura et bona, III-IV.
[12] https://txcatholic.org/wp-content/uploads/2017/12/Conscience-Formation-2017.pdf
As far as possible conscience should take account of the good of all, as expressed in the moral law, natural and revealed, and consequently in the law of the Church and in the authoritative teaching of the Magisterium on moral questions. Personal conscience and reason should not be set in opposition to the moral law or the Magisterium of the Church.
~Catechism of the Catholic Church, No. 2040
Texas law and policy:
- When disputes arise between providers and patients, an ethics committee can play a valuable role in resolving conflicts and protecting autonomy within the physician-patient relationship.The Texas Advance Directives Act establishes a process by which physicians may submit intractable disagreements with surrogates over the withdrawal of life-sustaining treatments to an ethics committee for review. If the ethics committee does not agree with the physician’s decision, then he faces criminal and civil liability if he fails to provide the treatment requested by the patient or surrogate. However, if the ethics committee agrees with the physician’s decision to remove treatment, the physician is granted criminal and civil liability immunity for following the ethics committee review procedure. If the patient or surrogate disagrees with the physician and the ethics committee ruling they have ten days after the ruling to effectuate a transfer to a provider who is willing to provide the treatment demanded by the family. If no willing alternate provider is located, the physician and hospital are legally authorized to withdraw all life-sustaining treatment. While the process is designed to provide an objective ethics committee review of the case, further safeguards are needed to reduce the potential for conflicts of interest or mistaken quality of life decisions. [1]
[1] Texas Advance Directives Act. §166.046.
Bill Summaries:
- Oppose repeal of ethics committee review process, including excessive extension of the number of days that inappropriate or ineffective interventions are required.
- Oppose legislation that removes provisions in current law that are designed to balance patient rights and healthcare provider conscience rights when family members request treatment that healthcare professionals determine to be inappropriate.
- Oppose bills that remove provisions in current law that invalidate an advance directive for pregnant patients. The TCC opposes this bill which removes important protections for unborn children.
- Support ethics committee reform bills which seek to prevent financial conflicts of interest and mistaken quality of life decisions.