Schiavo prompts questions on care

The ongoing debate over the fate of Terri Schiavo, the brain-damaged Florida woman whose feeding tube was recently removed, has stirred questions among Catholics of the Albany Diocese about what directives in end-of-life care the Church permits.

According to Brother Daniel Sulmasy, OFM, who is also a medical doctor and a bioethicist at St. Vincent's Medical Center in New York City and New York Medical College in Valhalla, living wills and healthcare proxies are acceptable for Catholics.

A living will documents a person's wishes regarding various healthcare treatments for a time when they can't personally communicate those wishes. A healthcare proxy (referred to in other states as a "durable power of attorney") involves appointing a healthcare agent (usually a family member or close friend) to make healthcare decisions for when someone is incompetent or incapacitated.

Cautions

The problem with living wills, said Kathleen Gallagher, director of pro-life activities for the New York State Catholic Conference, is that they "force people to put in writing today what their wishes would be at some future time when they have unforeseen circumstances and unknown medical conditions."

The Catholic Conference advocates on behalf of the state's bishops on public policy matters.

Of the two options, Brother Daniel advised, "a healthcare proxy is preferable -- and that's not just a Catholic preference -- because not even I could write a living will that would be good enough, that could cover all the things that could possibly happen to me."

Difficult choices

For example, he said, secular law would allow a diabetic to refuse insulin, but Church teaching would advise taking insulin, since the benefits of living another 40 or 50 years would outweigh the burdens of daily self-injection.

However, he continued, if that diabetic had been burned in a fire and was days away from dying, injections of insulin could be considered a painful and unnecessary burden.

That's why a healthcare proxy is a better idea, he said; "a living will can't [predict] any of that."

Church teaching

As for specific healthcare treatments, abortion, sterilization and euthanasia are prohibited for Catholics; but, aside from those, there is no blanket set of directives that would apply to all situations.

Mrs. Gallagher pointed out that Church teaching is very complex and decisions must be made on a case-by-case basis.

"There's a broad range of treatments that could be withheld or withdrawn consistent with Catholic teaching," Brother Daniel stated. "The teaching is permissive, not mandatory; you're morally permitted not to take a particular treatment" if desired.

Burdens and benefits

He gave the example of a cancer patient whose doctor offers an experimental chemotherapy treatment that gives a one-percent chance of survival.

"Are you morally required to accept [treatment], or morally required to refuse it by Catholic teaching?" Brother Daniel asked and then gave the answer: "Neither." However, in that case, he added, "the burdens are disproportionate to the benefits" of treatment.

That's the bottom line, according to the bioethicist: The Church advises that Catholics have "an obligation to use treatments that have a reasonable chance of working, where the benefits outweigh the burdens of that treatment."

Schiavo case

Both Mrs. Gallagher and Brother Daniel said that the Schiavo case involves a very narrow set of circumstances that can't be applied to all end-of-life situations.

Mrs. Schiavo collapsed 15 years ago, presumably due to a potassium imbalance that temporarily deprived her brain of oxygen, and has received nutrition through a feeding tube.

"People are getting confused by this case," Brother Daniel said. "There are very few people in a vegetative state, and it's very rare to have such rancorous disagreements among family members. Do not generalize from this case."

Mrs. Gallagher noted that secular law on such cases is different in Florida, where Mrs. Schiavo lives, than in New York. "In New York State," she explained, "we have case law that says there must be 'clear and convincing' evidence of a person's intentions before you can remove food and water. In Florida, it's 'reasonable' evidence."

Food and water

Mrs. Gallagher said that the Church advises "there should always be a presumption in favor of food and water, even if it is artificially provided."

In 2004, Pope John Paul II wrote that providing food and water -- even to a patient in a "vegetative" state -- is "morally obligatory."

Whether Mrs. Schiavo is actually in a vegetative state is being disputed. Regardless, said Brother Daniel, her case "is very different from the circumstances of a person dying of Alzheimer's disease or cancer."

People appointing healthcare proxies or making living wills, he said, should remember that "the Church does not teach that you must take all treatments at all times."

Proxy forms

Even though New York State's healthcare proxy law was enacted in 1990, only 15 percent of New Yorkers have appointed proxies to date.

"If people would take the time [to do so], they wouldn't be in the same situation as the Schiavo family," Mrs. Gallagher stated.

Brother Daniel cautioned that if a Catholic feels that he or she cannot bear to undergo a particular form of treatment, he or she should speak with a member of the clergy or a chaplain.

(Proxy forms are available on the Catholic Conference's website, www.nyscatholic.org. To find them, click on "resources," then on "conference publications," and scroll down to the bottom of the page.)

'Five Wishes' a problem for Catholics

A document called "Five Wishes" that has become popular for use as both a living will and a healthcare proxy form is problematic for Catholics, according to the National Catholic Bioethics Center in Philadelphia.

A newly issued critique of Five Wishes, published in "Ethics and Medics" by the NCBC, says that Catholics "should be wary about making use" of the Five Wishes document, since it offers "questionable options" for health care.

"The central concern about the 'Five Wishes' is that it allows the removal of food and water from a patient simply because he or she has suffered brain damage and is not likely to recover from that condition. There is no requirement that the patient be dying," notes the author, Dr. Edward Furton, who is "Ethics and Medics" editor.

The conditions referred to would include "the so-called persistent vegetative state," he writes, adding: "Options are presented in the 'Five Wishes' that could lead to acts of euthanasia by the patient's family, loved ones or healthcare personnel." (KB)

(3/31/05)