Q: Is a “do-not-resuscitate” order ever ethical? Shouldn’t a patient in an emergency situation always be resuscitated, so that the family can evaluate with some time and care what are the limits of ordinary and extraordinary care (and is that distinction used anymore)? — K.T., Kansas City, USA.
William E. May offers the following response:
A: The Church does not explicitly address the morality of a “do-not-resuscitate order,” but it still uses the distinction between “ordinary” or “proportionate” (=morally obligatory) and “extraordinary” or “disproportionate” (=morally not obligatory) treatments. Moreover the Church clearly teaches that it is morally wrong to impose on anyone the obligation to accept treatments that impose undue burdens on him, his family, and the wider community or to accept treatments that do not offer reasonable benefits or are useless or futile. This is the teaching found both in the Congregation for the Doctrine of the Faith’s May, 1980 Vatican Declaration on Euthanasia (“Iura et Bona”), Part IV on “Due Proportion in the Use of Remedies,” and in the United States Conference of Catholic Bishops’ Ethical and Religious Directives for Catholic Health Care Facilities.
Before examining how the distinction between “ordinary/proportionate” and “extraordinary/disproportionate” treatment relates to the morality of a “do not resuscitate” order, we need to know the purpose of such an order, one intimately linked to the application of cardiopulmonary resuscitation (CPR).
Cardiopulmonary resuscitation (CPR) and “do-not-resuscitate” directives
CPR can be administered both in the hospital for patients suffering cardiac arrest or outside a hospital by rescue crews called to save the lives of persons suffering cardiac arrest, and rescue teams routinely give CPR immediately. CPR very often saves lives, and persons whose lives have been saved by it and their families are then grateful to have their lives extended.
But one can ask whether CPR, despite its good effect of saving a cardiac victim’s life, is always the morally right thing to do and in the true best interests of the person. A DNR is an advance directive, legally recognized, giving a person or, if not competent, his health care proxy, authority to prevent CPR or, if it has begun, to withdraw it.
“extraordinary” or “disproportionate”
Both the Vatican Declaration on Euthanasia and the United States Conference of Catholic Bishops (see footnote 1) explicitly affirm that a person or, if the person is incompetent, his proxy health care decision-maker can rightly refuse treatments that do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.
Excessive burdensomeness is perhaps the major criterion for determining whether a proposed treatment is “extraordinary/disproportionate.” Excessive burdensomeness is the genus, and species of such burdensomeness include the treatment’s riskiness, its bad side-effects and bad consequences on the life of the person [e.g. it may so disable a person he is no longer able to do his job and support his family; he may have to move to a different climate, leaving home, friends, and so forth]; the excessive pain of the treatment, and excessive expense that would imperil the economic security of the patient, the patient’s family, and/or the community. Withholding or withdrawing such treatments is not euthanasia or a choice to kill oneself or another for merciful reasons. One does not judge a life excessively burdensome, one judges a treatment excessively burdensome. In making this judgment the “physical and moral resources of the patient” — his or her “quality of life” in that sense — can rightly be taken into account.
Another criterion helping us judge whether a given treatment, for a given patient, is “extraordinary” or “disproportionate” is the criterion of usefulness. In the Catholic tradition a means has been judged useless in the strict sense if the benefits it promises are nil or useless in a wider sense if the benefits conferred are insignificant in comparison to the burdens it imposes.
A moral principle
This principle can be expressed as follows: “A ‘do-not-resuscitate’ order is morally permissible if one can judge that CPR is excessively burdensome for this patient, taking into account his situation and his physical and moral resources, or that CPR imposes excessive expense on the family or community.”
CPR can be administered either in a hospital to a patient who suffers cardiac arrest or outside a hospital by a rescue team to a person who stops breathing because of cardiac arrest. Examples illustrating how the moral principle justifying a “do-not-resuscitate order” in a hospital or outside a hospital will now be given.
The hospital scenario
Consider the following: a quadruple amputee who must live in a bucket and needs others to feed him, clothe him, and do everything for him; a person suffering from multiple sclerosis, blind, fed by nasogastric tubes with his conditioning worsening; persons in the final stages of pancreatic cancer. With others, I think that he or his proxy could refuse CPR and insist that he not be resuscitated because of the terrible burdens he would then be made to suffer as a result from his underlying maladies and pathologies.
I also think that a senile hospital patient suffering from advanced cancer, but not imminently in danger of dying although in need of periodic chemotherapy or radiation therapy who then contracts pneumonia and then suffers cardiac arrest could also refuse CPR and post a “do-not-resuscitate” order to accept death by pneumonia rather than be resuscitated, rather than, as a result of the CPR and having the pneumonia cleared up by antibiotics, be made to suffer from advanced cancer.
The “not-in-the-hospital” or home scenario
Analogous situations can occur in the home when a person suffers cardiac arrest and a rescue squad is summoned that routinely administers CPR because by doing so they correctly believe that they can prevent the person from dying if the procedure is successful. If the person suffering cardiac arrest is in very bad shape and in need of constant care at home, it seems to me that, taking into account his state and physical and moral resources the moral principle justifying a “do-not-resuscitate order” is applicable.
It is morally obligatory, as the magisterium teaches, to provide by tubal means food and hydration to persons said to be in the “vegetative state” in order to sustain their lives. Such provision of food and hydration is not a treatment but is part of the ordinary care that ought to be given to sick and debilitated non-dying persons. However, a person is under no obligation to allow himself to be put in this condition. Knowing that if a person is deprived of oxygen (breathable air for more than, say 5 or 10 minutes), it seems to me that a person at home and not in the hospital (or one in the hospital as well) could ask for a “do-not-resuscitate” order if more than 10 minutes had elapsed since he had been able to breathe air or get oxygen to his brain in order to avoid being placed in this stage of existence. I suggest this as an example when the principle formulated is applicable, but I may certainly be mistaken.
I hope that these reflections answer the question raised. I acknowledge that advocates of euthanasia use “do-not-resuscitate” orders as a means for securing the death of the patient, but such orders of themselves can be used for morally bad purposes or morally good ones.
Notes The Vatican Declaration on Euthanasia thus says that a “correct judgment” about treatments to be used can be made “by studying the type of treatment, its degree of complexity or risk, its cost and the possibility of using it, and comparing these elements with the results that can be expected, taking into account the state of the sick person and his or her physical and moral resources…one cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome.”
Directive 56 of the USCCB’s Ethical and Religious Directives for Catholic Health Care Facilities, referring to the Vatican Declaration, identifies “proportionate” or “ordinary” means as those offering “a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense of the family or the community.” Directive 57 states: “A person may forego extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patient”s judgment do not offer a reasonable hope of recovery or entail an excessive burden or impose excessive expense on the family or the community.” Albert S. Moraczewski, O.P., “Do-Not-Resuscitate Orders,” in Catholic Health Care Ethics: A Manual For Practicioners (Second Edition), edited by Edward J. Furton with Peter Cataldo and Albert S. Moraczewski, O.P. (Philadelphia, PA: The National Catholic Bioethics Center, 2009), pp. 210-213.  See Pope John Paul II, Address of March 20, 2004 to International Federation of Catholic Medical Associations on Feeding and Hydrating Persons in the “Vegetative” State. http://www.vatican.va/holy_father/john_paul_ii/speeches/2004/march/documents/hf_jp-ii_spe_20040320_congress-fiamc_en.html.
See also Congregation for the Doctrine of the Faith, “Responses to Certain Questions of the United States Conference of Catholic Bishops Concerning Artificial Nutrition and Hydration,” accessible at http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_20070801_risposte-usa_en.html.
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William E. May, is a Senior Fellow at the Culture of Life Foundation and retired Michael J. McGivney Professor of Moral Theology at the John Paul II Institute for Studies on Marriage and Family at The Catholic University of America in Washington, D.C.[Readers may send questions regarding bioethics to firstname.lastname@example.org. The text should include your initials, your city and your state, province or country. The fellows at the Culture of Life Foundation will answer a select number of the questions that arrive.]