My husband, Roger, is seventy-one. He smoked heavily for many years and retired from his job as a lithographer nine years ago because of health problems. Six years ago he had surgery to improve circulation in his legs, finally quit smoking, and was better for a while. But in the past year or two he has had more and more problems. Hating hospitals as he did, Roger put off dealing with his problems as long as he could. In the end, the doctors said he needed a multiple bypass and an operation on his right carotid artery. Two weeks ago today, the surgeon worked on Roger about six hours. Something went wrong, and he has been in intensive care since then. He breathes with a respirator, is fed through a tube to his stomach, and receives all sorts of medications intravenously.
The doctor had warned us that, even if Roger’s surgery went well, his recovery would be difficult, because he has so many health problems. But whatever went wrong during the surgery damaged his brain. He is not what they call “brain dead,” but they say he has not come to. Still, when I talk to him and stroke his forehead, I sense that he responds. A tear comes to his eye and his face softens, as if he were about to smile.
On the fifth day they did an encephalogram. It was “very abnormal.” The next day, which was our golden wedding anniversary, a brain scan was done, and the doctors talked with me. The neurologist told me the scan showed many damaged spots on both sides of Roger’s brain and in different parts of it, and said he would never regain consciousness. When I said he responds to me, the surgeon said I am imagining it. He argued that if Roger were conscious, he would show signs of needing the sedation that had to be withdrawn on the third day (to exclude it as a possible cause of his not waking up). The neurologist and the surgeon also agreed that, even if Roger regained consciousness, he never would enjoy any “real quality of life.” The intensive care doctor took the same view and urged that the respirator be removed “to get it over with.”
I could not accept that, and the children also were very upset. Our eldest son is involved in a prolife organization whose chairman, Dr. Levi, is a believing Jew who happens to be a neurologist. We got him to come down to the hospital to look at the report on the scan and examine Roger. Dr. Levi also thinks Roger is unconscious, probably never will wake up, and almost certainly will die within a few weeks no matter what is done for him. He told me it does not seem possible that Roger responds as I think he does, but, with a person in his condition, nobody can say for certain. And, though Dr. Levi spoke very gently, he said that, if Roger did wake up, he would be demented, blind, have little or no ability to use language, be unable to recognize things, and be completely or almost completely paralyzed. I asked what to do about the respirator. Dr. Levi said Roger might be able to do without it if he were weaned from it gradually. But he did not want to tell me what to do, since I am not a Jew. So, I talked with the Catholic chaplain at the hospital, who suggested I talk with you.
I hope you can help me make the right decision. The intensive care doctors have said over and over that Roger could survive for a long time, but will die of something sooner or later, and in his condition, it might as well be sooner. Yet I still cannot bring myself to agree. At the same time, though Roger never told anyone what he would want in this sort of situation, I am sure he would not want to go on with intensive care without hope of recovering. The intensive care unit seems to me more intensive than caring; I sometimes imagine it is a horrible laboratory where mad scientists are experimenting on people. Going on also will be difficult for me. Even though Medicare will cover most of the cost, the bills will add up. Then too, I have to be driven to the hospital, which is in the city, forty miles away, because I have never got used to driving in heavy traffic.
Perhaps you should know that Roger is not a Catholic. He was raised as a Baptist and always has been a good man and a serious Christian. But because he smoked and drank, his church refused to baptize him, and, except for special occasions such as weddings and funerals, he never would go into a church again. Still, he supported me in raising our children as Catholics, and I must confess that since the last of our children left home ten years ago, he has been more faithful to religion than I have. He has continued spending every Sunday morning reading the Bible and praying, while I have been going to Mass only occasionally.
The question is what sort of care is morally required and appropriate for this patient. The questioner rightly rejects the homicidal proposal to remove the respirator so as “to get it over with.” Though intensive care benefits the patient insofar as it helps him survive, it also imposes significant burdens. To remove the respirator in order to avoid such burdens would not be homicidal. However, withdrawing the respirator suddenly would be morally questionable, since that would deprive the patient of all care and risk leading others in similar cases to engage in homicide. A morally acceptable alternative would be to remove the patient from intensive care and attempt to wean him from the respirator. The questioner should be encouraged to have her husband baptized as soon as possible and to repent her neglect of her faith.
Despite the great difficulty of your painful situation, you have put the question very clearly. I can respond briefly and directly. First, I agree with you that the respirator should not be removed unless Roger is weaned from it gradually. Second, you should consider removing him from intensive care. Third, if Roger is removed from intensive care, other care appropriate to his present condition should be continued. I shall explain each of these three points.
The physician who urged that Roger’s respirator be removed “to get it over with” apparently thinks its rapid removal would bring about death and that would be a good thing—not, of course, in itself but as a means of resolving the present situation. Believing Roger never will enjoy “real quality of life,” he and the other physicians think his life should be ended. Removing the respirator would do that as surely and promptly as anything else, and undoubtedly it would be more psychologically acceptable to the physicians than, say, giving Roger a deadly drug. Moreover, if you agreed, they could remove the respirator without risking professional and/or legal sanctions. Still, it seems clear that the proposal to remove Roger’s respirator was homicidal. Since consenting would have been consenting to murder, you rightly rejected it.
By contrast with the physicians’ thinking, yours is sound and reasonable. Desiring that Roger live, and expecting that removing the respirator would lead promptly to his death, you cannot bring yourself to agree. Yet you believe Roger “would not want to go on with intensive care without hope of recovering,” and you are quite reasonably concerned about its mounting costs and other burdens on you and others.153
I believe someone thinking about a similar case could decide to remove the respirator without judging that the patient’s quality of life warranted ending it and adopting the proposal to do so. The choice could be simply to end all care of the patient so as to avoid the burdens of continuing it. In that choice, the patient’s foreseen death would not be intended, but only accepted as a side effect. Even if not homicidal, however, a choice to end all care for anyone is morally questionable for at least two reasons.
First, ending all care would be appropriate only if nothing that could be done for the person would promise any benefit worth the trouble of pursuing it. But even when a patient is in Roger’s condition, various measures far short of the intensive care he is receiving can offer significant benefits. One of these is sustaining the patient’s life briefly in a more humane environment, until death results less abruptly from underlying pathological conditions. Then too, care can manifest respect and love for the patient as a person, and so provide the benefits inherent in a good interpersonal relationship, both to the one cared for and to everyone who respectfully and lovingly wants the care to be provided or helps provide it.154
Second, even if the intention in ending all care is not homicidal, that step brings about death so surely and abruptly that people generally will find it difficult, even impossible, to distinguish it from homicide. Failing to make a clear distinction, some will go on to approve and even carry out homicidal choices, while only psychological inhibitions will keep some others from doing so. In my judgment, then, a choice to end all care is warranted only if it is morally obligatory—for example, if a shortage of respirators meant continuing care for a patient with very poor prospects would unfairly deprive another patient with far better prospects of care he or she needed to survive and recover.
Dr. Levi plainly doubts that Roger responds to your voice and presence as you think he does, yet he grants—and I agree with him—that nobody can know for certain. In deciding what to do, therefore, take into account your belief that Roger is somewhat aware. If he is, keeping up a losing fight to sustain his life may be imposing an awful burden on him. Put yourself in his place and, bearing in mind his dislike of hospitals, ask whether he would wish to go on with that fight. If not, loving him as you do, you will want a different approach.
Without ending all care for Roger, you could direct that he be moved out of the intensive care unit. Intensive care ordinarily is supplied temporarily to sustain only the lives of people who have some reasonable prospect of recovering sufficiently to go on without it. It is extremely expensive and, even if Medicare covers most of the cost, it burdens taxpayers, and the copayment on the physicians’ fees burdens you. Moreover, intensive care facilities are more or less limited and should be available to those likely to benefit more from them. And, as you point out, unless there is some significant likelihood of eventual recovery, this form of care is repugnant both to those who undergo it and to their loved ones. So, intensive care certainly is not morally required for patients unlikely to recover. Therefore, you can rightly have Roger removed from intensive care, and so end the constant monitoring and multiple medications being administered intravenously. In doing that, you need not at once have the respirator removed. But if you have not done so already, you could direct that no emergency measures—resuscitation, emergency surgery, and so on—be taken to sustain his life.
You also can rightly direct that he be weaned from the respirator, so that the machine will not be an obstacle to you and your family and friends being with him as he dies. At the same time, you can direct the attending physicians to leave the stomach tube in place to supply water, nutrition, and any medications he regularly takes by mouth that still would help sustain him. And, given your belief that he is not completely unconscious, it would be reasonable to ask that medication be administered regularly to mitigate his possible suffering, while taking care to avoid suppressing respiration.
In giving these instructions, your intention should be to continue appropriate care until Roger dies from the illness that has caused both him and you so much trouble and suffering, while giving up the clearly hopeless battle indefinitely to sustain his life.
That is not surrendering unconditionally to sickness and death. We look for the resurrection of the dead and the life of the world to come. The care Roger needs most is not for his bodily life but for his soul. Without delay and before removing him from intensive care, tell the hospital chaplain that, though Roger had wanted to be baptized and regularly prayed and read the Bible, he never was baptized. Even if he never chose to become a Catholic, he plainly is a man of faith who desired baptism and showed that he was committed to living a Christian life (see CIC, c. 865, §2). If you cannot reach the chaplain or he hesitates to baptize Roger, you can and should do it yourself.
Having seen to Roger’s baptism, you will be able to hope that he will soon be in heaven. Wanting, as you surely will, to look forward to joining him there, you should examine yourself and identify the ways you have not been faithful in fulfilling your religious duties, repent and confess those shortcomings as well as any other serious sins, and recommit yourself to a devout Catholic life. I hope and pray that you and Roger will gain by these spiritual means what medical technology cannot give: restored, rich, carefree, and unending life together.
153. The questioner’s statement, “The intensive care unit seems to me more intensive than caring; I sometimes imagine it is a horrible laboratory where mad scientists are experimenting on people,” forcefully expresses repugnance to inappropriate, ongoing intensive care. However, it obviously is not an accurate general description of intensive care units and the professionals who staff them. Their skilled and dedicated work generally provides great benefits for suitable patients.
154. See Germain Grisez, “Should Nutrition and Hydration Be Provided to Permanently Unconscious and Other Mentally Disabled Persons?” Linacre Quarterly, 57:2 (May 1990): 30–43.