As the Community Ethics Committee undertakes to comprehend and sort through the brutally hard questions around medical futility, a story this past weekend in Toronto Star posed the quandary this way: “Who decides when critically ill patients should be left to die without medical intervention or given every chance to live? Doctors? Patients? Family?”
Twice in recent weeks, a board representing the Canadian province of Ontario has been asked to resolve what critical care doctors and families could not. One patient is a 13-month-old, the other an elderly man, but both are at the end of their lives. And both cases pit the Catholic faithful against medical judgement.
The Star writes: “A lack of legal and ethical clarity around the end-of-life question in Canada has made the decision-making process a perplexing minefield. There are no clear provincial, federal or medical protocols to break the deadlock when the wishes of patients and their families come into conflict with the medical judgment of physicians.’’
The Star told the story of Maria and Desmond Watson, a couple married 69 years. Desmond has spent more than a year at Oakville Trafalgar Memorial Hospital, where the dispute between doctors and Maria over whether to continue aggressive care to keep him alive was decided on Monday in Maria’s favor by the Consent and Capacity Board.
The CCP is a provincial board certain to set off “death panel” alarms for those given to such demonization of humans making hard decisions. According to a provincial website, it consists of psychiatrists, lawyers and members of the general public, and is charged with hearing and resolving health-care disputes largely over consent and decision-making. The CPB only recently denied an appeal by the parents of Joseph Maraachli to force a London, Ontario hospital to perform a tracheotomy on their 13-month-old son, so that he could die at home. “Baby Joseph,” a cause celebre for the pro-life movement, this week was transported by private plane to St. Louis, where a Catholic hospital is expected to perform the tracheotomy.
The organization Priests for Life sponsored the child’s transfer. Rev. Frank Pavone said Joseph "needs to be in a hospital that cherishes life over the bottom line.” Priests for Life will ask supporters to fund this, and such is the dramatic portrayal of Joseph’s rescue on its website that you’d think it was the Raid on Entebbe.
Cost was never mentioned in the hearings regarding Desmond Watson’s fate. And yet the Star reported that Maria “has a stack of bills from the hospital for $700 a day. They began coming in September after she refused to have him discharged to a long-term care facility she says was unequipped to handle his needs. At that daily rate for care, Desmond’s 14-month stay at Oakville Trafalgar rings in at about $300,000 so far. She’s ignoring the bills.”
Maria wonders, “What am I going to do?”
On so many levels, that truly is the question.
According to the Star, Ontario law requires that an incapable patient’s values and beliefs and previous wishes for care be considered in determining their best interests. But during the hearing, Watson’s medical team admitted never having even inquired about Desmond’s values or beliefs. Monday’s ruling for the surrogate is perhaps attributable to this profound oversight. “By any objective medical standard, Mr. Watson should be allowed to pass,” the family’s lawyer, Mark Handelman, said. “Except that’s not how we make decision in this province. We factor in a person’s values and beliefs. That did not happen in this case.”
Both the Maraachlis and Watsons are devout Catholics, but a case could be made that their doctors’ recommendations against a tracheotomy and to discontinue aggressive treatment align well with church teaching.
According to Catholic Catechism: “Even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted. The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only foreseen and tolerated as inevitable. Palliative care is a special form of disinterested charity. As such it should be encouraged.”
And: “Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of "over-zealous" treatment. Here one does not will to cause death; one's inability to impede it is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected.”
This teaching seems to fit within Judaism’s dual prohibition against hastening death and prolonging dying.
On Monday, palliative care physician Brian Berger told the Star that his hospital, York Central, encourages an early palliative care consultation with patients. “Having borne witness to thousands of deaths, it takes a lot of love to want someone here forever but more love to know when to let go. Letting go is the ultimate form of love, and if you are a religious family you must know that he or she will go to a better place.”
“It is an uphill battle dealing with families who have unrealistic expectations of their loved one’s prognosis and return to a normal life,” Peter Huggonson, an intensive care nurse at Toronto General Hospital, told the Star. Huggonson said he has “seen veteran bedside nurses almost in tears because they believe they have reduced themselves to the level of a torturer.”