Safeguarding patients' dignity. The revised directives discuss spiritual and professional considerations

The Catholic health ministry recognizes that caring for the spiritual nature of a person is a high priority. The rights of patients and residents in their relationship with care givers are also important. These topics are treated in Parts 2 and 3, respectively, of the Ethical and Religious Directives for Catholic Health Services. This article focuses on those directives. Directive 10 says pastoral care should be available to all persons in a Catholic healthcare facility, no matter their religious affiliation. Directives 12 to 20 are concerned with the reception of the sacraments of baptism, penance, anointing, and communion by Catholics. Directive 21 discusses the appointment of priests and deacons to the pastoral care staff. Directive 23 reminds care givers that respect for human dignity must inform all Catholic healthcare. Directives 24 and 25 discuss norms for responding to advance directives and the responsibilities of surrogates. Directives 26 to 28 are concerned with free and informed consent on the part of patients and surrogates. Directives 29 to 30 say care givers have a moral obligation to preserve a patient's anatomical and functional integrity. Directive 31 discusses the ethical limits on medical research, and Directive 33 discusses therapeutic procedures likely to harm the patient. Directive 34 says care givers must protect patients' privacy. Directive 36 discusses the care of women who have been raped, including treatment that would prevent ovulation as a result of the rape. Directive 37 says ethical consultation should be available to all Catholic facilities, usually through an ethics committee.     

Healthcare and social responsibility. The revised directives clarify the Catholic position

The Catholic Church participates in the U.S. healthcare system by reason of its contribution to the common good of society. To facilitate this, the Ethical and Religious Directives for Catholic Health Care Services set forth certain normative principles. Catholic healthcare is dedicated to promoting human dignity and the sacredness of life; it has an "option for the poor"; it seeks the common good, cooperating with other providers toward that end; it prohibits abortion, in vitro fertilization, contraceptive sterilization, and assisted suicide procedures in free-standing Catholic healthcare institutions. This article focuses on the directives in Parts 1 and 6 of the ERD. Directive 2 calls for mutual respect among care givers. Directive 3 discusses ways to care for people "at the margins of society." Directive 4 describes the medical research permitted in Catholic facilities, and Directives 5 and 9 suggest how such facilities can best perpetuate their Catholic identity. Directive 7 mandates that Catholic facilities treat employees justly. Directive 8 says that such facilities must observe canon law in transferring sponsorship or in founding, closing, or selling an institution. Directive 68 suggests that the bishop be involved in a proposed partnership that may infringe upon Catholic identity. Directive 70 urges Catholic facilities to avoid scandal, and Directive 69 warns that some forms of cooperation are unethical even when scandal is not present.     

Care of the dying: a Catholic perspective. Part II: Social and political context--Catholic providers must exemplify a caring community. Catholic Health Association

Fears of abandonment and isolation in an institution have increased the public demand for euthanasia and assisted suicide. To quell this movement, Catholic healthcare providers must provide a caring community where patients and care givers enable each other to confront the fear of death and find support in living with human limitation. To begin to address the social and political dimensions of issues about the end of life, Catholic healthcare providers must use clear and consistent definitions of the terms used to describe these issues, such as death with dignity, right to die, euthanasia, allowing to die, and assisted suicide. By acknowledging the influence of the media in forming attitudes and opinions, healthcare institutions can seize opportunities for public education on fundamental human and religious values. The first effort has to be directed toward educating members of the media. The Catholic Church supports the concept of advance directives, which provide an opportunity for people to express their values and the ways they would expect those values to be honored in decisions about medical treatment. Courts' role in resolving decisions about treatment should be limited. Patient self-determination is best exercised when a patient (or surrogate), in consultation with a physician, decides what is best. Catholic healthcare institutions should advocate for legislation that fosters an appropriate balance between protecting a patient's right to self-determination and the state's interests to protect life. At the same time, institutions' advocacy efforts should demand sufficient resources for holistic care for the dying.     

Care of the dying: a Catholic perspective. Part IV: Theological, moral, and pastoral response--the transformation of suffering. Catholic Health Association

People struggle to find meaning in suffering and death. In a culture that cannot depend on religious insights into suffering to address the deeper questions (e.g., Why me?), all kinds of interventions, even euthanasia and assisted suicide, may seem inevitable. Catholic healthcare providers can respond by offering patients, families, and care givers a vision of how suffering can be understood. Based on the power of divine love to transform suffering and death from absolute evils to personal triumphs, the moral principles the Catholic Church upholds can provide a hopeful perspective for healthcare professionals who care for the dying. Three principles support Roman Catholic teaching on conserving health and life: sanctity of life, God's dominion and human stewardship, and the prohibition against killing. These principles by themselves are insufficient as a moral or pastoral response to the care of the suffering and dying. Action is also required. Moral virtues must be reflected in ethical behavior and in pastoral practice so that we may enact our Christian vision in the face of suffering and death. Attention to our character as providers and our ethical practices is of grave importance in these days when euthanasia and assisted suicide are being promoted so aggressively. To carry on Jesus' healing mission by responding to human suffering and death, healing communities must embody virtues that bear convincing witness in both a personal and a corporate manner regarding the care of the dying. Three characteristics of a virtuous community stand out: interdependence, care, and hospitality. By being a virtuous community, we may be able to address many of the concerns that motivate people to consider euthanasia.(ABSTRACT TRUNCATED AT 250 WORDS)     

Artificial Nutrition and Hydration in Catholic Healthcare: Balancing Tradition, Recent Teaching, and Law

Roman Catholics have a long tradition of evaluating medical treatment at the end of life to determine if proposed interventions are proportionate and morally obligatory or disproportionate and morally optional. There has been significant debate within the Catholic community about whether artificially delivered nutrition and hydration can be appreciated as a medical intervention that may be optional in some situations, or if it should be treated as essentially obligatory in all circumstances. Recent statements from the teaching authority of the church have attempted to clarify this issue, especially for those with a condition known as the persistent vegetative state. I argue that these recent teachings constitute a “general norm” whereby artificial nutrition and hydration are considered obligatory for most patients, but that these documents allow for exception in cases of complication from the means used to deliver nutrition and hydration, progressive illness, or clear refusal of such treatment by patients. While the recent clarifications do not constitute a major deviation from traditional understanding and will rarely conflict with advance directives or legal statutes, there may be rare instances in which remaining faithful to church teaching may conflict with legally enshrined patient prerogatives. Using the Texas Advance Directives Act as an example, I propose ways in which ethics committees can remain faithful to their Roman Catholic identity while respecting patient autonomy and state law pertaining to end of life health care.     

Reclaiming our moral tradition. Catholic teaching calls us to accept the limits of medical technology

The success of science and medical technology has led to medical brinkmanship, pushing aggressive treatment as far as it can go. But medicine lacks the precision necessary for such brinkmanship to succeed, and the resulting cycle of expectation and disappointment in technology has, in part, led to an increasing acceptance of euthanasia and assisted suicide, linked closely with advocacy for patient autonomy. At the opposite extreme lies medical vitalism, which refers to attempts to preserve the patient's life in and of itself without any significant hope for recovery. The Catholic moral tradition offers a middle ground, well expressed in the 1994 Ethical and Religious Directives for Catholic Health Care Services. The tradition does not deny the good of technology or state that some lives are not worth living. Rather, it calls us to accept the fact that medical technology has limits. In reclaiming this tradition, we reclaim the naturalness of death. Reclaiming the tradition has practical consequences for the use of life-prolonging technology at the end of life and for end-of-life decision making. These can be placed in three broad categories: the Christian understanding of care, the ambiguity inherent in end-of-life decision making, and the task of Christian formation.     

Removing life support: motivations, obligations. An opinion on NCCB Committee for Pro-Life Activities' statement on artificial hydration and nutrition

In April 1992 the Committee for Pro-Life Activities of the National Conference of Catholic Bishops issued a resource paper titled "Nutrition and Hydration: Moral and Pastoral Reflections." At best, this document and its conclusions may be viewed as a pastoral statement, offering some tentative reasoning and conclusions to be considered in cases that concern the use of medically assisted nutrition and hydration. When discussing the question, is the withholding or withdrawing of medically assisted hydration and nutrition always direct killing? the document applies two principles--"no reasonable hope of benefit" and "involving excessive burdens." The document's crucial part is its admission that artificial hydration and nutrition may be removed without the intention of causing death, and that "this kind of decision should not be equated with a decision to kill or with suicide." The committee assigns decision-making responsibility to patients, families, and healthcare professionals, but continues its discussion for 20 pages and offers cautions conclusions concerning removal of such therapy. Two assumptions seem to underlie the document's overly cautious conclusions, the first being that mere vegetative function mandates continued life support. The first assumption overemphasizes the value of physiological functioning insofar as the purpose of human life is concerned. It also is contrary to the goal of medicine, which envisions restoration of cognitive-affective function as an element of successful therapy. The second assumption is that withdrawal of artificial hydration and nutrition from persons in PVS may lead to euthanasia. But mandating the continuation of nonbeneficial therapy simply because it prolongs physiological function seems to lead people to favor euthanasia rather than reject it.(ABSTRACT TRUNCATED AT 250 WORDS)     

Attitudes, sociodemographic characteristics, and actual end-of-life decisions of physicians in Flanders, Belgium.

AIM: To study the effect of sociodemographic and attitudinal determinants of physicians making end-of-life decisions (ELDs). METHODS: The physicians having signed 489 consecutive death certificates in the city of Hasselt (Belgium) were sent an anonymous questionnaire regarding their ELDs and another on their attitudes toward voluntary euthanasia (EUTH) and physician-assisted suicide (PAS). RESULTS: 55% response rate. Nontreatment decisions occurred in 16.7% of all death cases; in 16%, there was potentially life-shortening use of drugs to alleviate pain and symptoms; in 4.8% of cases, death was deliberately induced by lethal drugs, including EUTH, PAS, and life termination without explicit request by the patient. In their attitudes toward EUTH and PAS, the 92 responding physicians clustered into 3 groups: positive and rule oriented, positive rule-adverse, and opposed. Cluster group membership, commitment to life stance, years of professional experience, and gender were each associated with specific ELD-making patterns.     

安乐死离我们还遥远临终关怀离我们却很近

我国自20世纪80年代就开始了对安乐死立法的讨论，有的人赞同安乐死，有的人反对安乐死。就我国现阶段的社会状况来说，尚不具备为安乐死立法的社会条件。而对于那些身患绝症、救治无望、极度痛苦的濒临死亡而又惧怕死亡的病人，如何解决他们生理的、心理的、生活的痛苦、焦虑与不安？临终关怀是最好的选择。     

Care of the dying: a Catholic perspective. Part I, Cultural context: a CHA document challenges care givers to define appropriate care for the dying

In a society tempted to adopt legalized assisted suicide and euthanasia as appropriate responses to dying, the healthcare community is challenged to nurture positive attitudes toward death among all ages and to help those with terminal illnesses to live well while dying. Whereas family and friends were once the primary care givers, now members of the healthcare professions are. This shift has introduced tensions between medical professionals and patients, including their families, in defining appropriate behavior toward the dying. To enable the terminally ill to live well while dying, we need to allow them to retain as much control as possible within the limits of belonging to a community. Also, we need to secure their network of significant relationships so they can experience the affective bonds of trust and love that support personal dignity and enhance the meaning of life. Medical technology is to be used in service of the total good of the patient. This includes not only the relief or cure that therapy can bring, but also what the patient prefers, values about life, and regards as giving ultimate meaning to life. Catholic healthcare institutions are challenged to promote a sensitivity and respect for cultural diversity as they respond to the needs of the dying and those who care for them.     

Prevalence and content of written ethics policies on euthanasia in Catholic healthcare institutions in Belgium (Flanders)

BACKGROUND: Euthanasia is performed worldwide, regardless of the existence of laws governing it. Belgium became the second country in the world to enact a law on euthanasia in 2002. Healthcare institutions bear responsibility for guaranteeing the quality of care for patients at the end of life, and for ensuring support for caregivers involved. Therefore, institutional ethics policies on end-of-life decision-making, especially on euthanasia, may be useful. METHODS: A cross-sectional mail survey of general directors of Catholic hospitals and nursing homes in Belgium was used to describe the prevalence and content of written ethics policies for competent terminally ill, incompetent terminally ill, and non-terminally ill patients. RESULTS: Of the 298 targeted institutions, 81% of hospitals and 62% of nursing homes returned complete questionnaires. Of these, 79% of hospitals and 30% of nursing homes had a written ethics policy on euthanasia. Of hospitals 83% and of nursing homes 85% permitted euthanasia for competent terminally ill patients only in exceptional cases in accordance with legal due care criteria and provisions outlined by the palliative filter procedure. Euthanasia for incompetent terminally ill patients was prohibited by 27% of the hospitals and by 60% of the nursing homes. For non-terminally ill patients, these figures were 43 and 64%, respectively. CONCLUSIONS: Catholic healthcare institutions in Belgium (Flanders) made great efforts to develop written ethics policies on euthanasia. Only a small group of institutions completely prohibited euthanasia. Most of the institutions considered euthanasia to be an option if all possible alternatives (e.g., palliative filter procedure, which contains more rigorous criteria than those in the Belgian Euthanasia Act), have been thoroughly investigated.     

Ethics Commission examines moral distinctions in using life supports

Deciding to Forego Life-Sustaining Treatment, a report of the President's Commission for the study of Ethical Problems in Medicine and Biomedical and Behavioral Research, examines four common medical-ethical distinctions. The report highlights the 1980 Declaration on Euthanasia and closely follows Catholic moral teaching on the following. Death by action versus omitting to act. The commission rejects the idea that a physician who fails to act should not be held responsible for a patient's death. Failing to resuscitate, for example, or to take other steps to prolong life, are just as much causes of death as a lethal injection. The health profession's traditional duty to act on the patient's behalf precludes any distinction between acts and omissions. Withdrawing versus withholding treatment. Acknowledging that initiating treatment may create an obligation to continue treatment, the commission suggests that distinguishing between withholding and withdrawing could encourage undertreatment and overtreatment. Fear of being unable to withdraw unsuccessful treatment could lead to physicians' failing to treat patients who might benefit from the therapy. Ordinary versus extraordinary means. The commission upholds this distinction. It suggests, however, that the phrase "proportionate versus disproportionate" better describes the moral issue involved in selecting treatments that, in relation to their expected benefits, impose no excessive burden on the patient or family. Regarding intended versus unintended consequences, the commission departs from Catholic tradition. It fails to acknowledge the significance of physicians' intentions. What matters instead, according to the commission, is whether physicians act within their authority as defined by society. Thus, the commission suggests, the use of pain medications that may cause death can be socially and legally acceptable.     

Attitudes on euthanasia, physician-assisted suicide and terminal sedation--a survey of the members of the German Association for Palliative Medicine

BACKGROUND: Due to recent legislations on euthanasia and its current practice in the Netherlands and Belgium, issues of end-of-life medicine have become very vital in many European countries. In 2002, the Ethics Working Group of the German Association for Palliative Medicine (DGP) has conducted a survey among its physician members in order to evaluate their attitudes towards different end-of-life medical practices, such as euthanasia (EUT), physician-assisted suicide (PAS), and terminal sedation (TS). METHODS: An anonymous questionnaire was sent to the 411 DGP physicians, consisting of 14 multiple choice questions on positions that might be adopted in different hypothetical scenarios on situations of "intolerable suffering" in end-of-life care. For the sake of clarification, several definitions and legal judgements of different terms used in the German debate on premature termination of life were included. For statistical analysis t-tests and Pearson-correlations were used. RESULTS: The response rate was 61% (n = 251). The proportions of the respondents who were opposed to legalizing different forms of premature termination of life were: 90% opposed to EUT, 75% to PAS, 94% to PAS for psychiatric patients. Terminal sedation was accepted by 94% of the members. The main decisional bases drawn on for the answers were personal ethical values, professional experience with palliative care, knowledge of alternative approaches, knowledge of ethical guidelines and of the national legal frame. CONCLUSIONS: In sharp contrast to similar surveys conducted in other countries, only a minority of 9.6% of the DGP physicians supported the legalization of EUT. The misuse of medical knowledge for inhumane killing in the Nazi period did not play a relevant role for the respondents' negative attitude towards EUT. Palliative care needs to be stronger established and promoted within the German health care system in order to improve the quality of end-of-life situations which subsequently is expected to lead to decreasing requests for EUT by terminally ill patients.     

Health charities, unethical research and organizational integrity

Organizations, particularly Catholic hospitals, schools and social service agencies, should re-examine their relationships to health and medical charities promoting unethical research such as human embryonic stem cell research and therapeutic cloning. Part 6 of the Ethical and Religious Directives provides a helpful framework for ethical analysis and action.     

Catholic healthcare as "leaven". To penetrate and renew society, Catholic healthcare must meet five requirements

Pope Paul VI described the church as the "leaven" of civil society. Catholic healthcare should strive to be the leaven of U.S. healthcare. To achieve this, it must do five things: Immerse itself in civil society. Catholic healthcare professionals and organizations should participate in efforts to improve public health, even when they are not in full agreement with those efforts. Provide high-quality care. Such care is not always easy to define, but Catholic healthcare can and should set high objective standards for the well-being of its patients. Minister to the suffering and dying. The Catholic view of suffering and death as necessary for human fulfillment is a countercultural idea in our society. Catholic healthcare should, while eliminating physical pain when possible, help people to die in a holy atmosphere. Be a responsible, just employer. Catholic healthcare should treat employees as individuals worthy of respect, not as economic units. Be advocates for the poor. Catholic healthcare should not only provide charity care for the poor; it should also work for universal coverage, care based on need rather than on ability to pay for it.     

Do German General Practitioners Support Euthanasia?

Objective: To learn more about the attitudes of German general practitioners (GPs) concerning euthanasia and the frequency of its performance in Germany.

Methods: 500 GPs from all parts of Germany were randomly selected from telephone listings, and were sent a postal questionnaire with anonymous return envelopes. Participants were asked to make decisions based on hypothetical scenarios involving terminally ill patients and were questioned about their attitudes towards active euthanasia or physician assisted suicide (PAS).

Results: The questionnaire was returned by 48% of all 481 eligible GPs (mean age 51 years, 68% male). Although the option of performing euthanasia was rarely chosen in hypothetical scenarios, its performance was considered acceptable by 34% (active euthanasia) and 80% (PAS). Seventy-seven percent of respondents believed that a comparison between euthanasia today and the atrocities committed during the 3rd Reich was not appropriate. Sixty-two percent of respondents had received requests for active euthanasia and 73% for PAS. Thirteen percent and 38% of respondents seem to have performed euthanasia themselves in the past.

Conclusions: The majority of German GPs reject active euthanasia and physician-assisted suicide (PAS). Nonetheless, requests for and performance of euthanasia do not seem to be a rare occurrence. Only a small proportion of respondents are willing to perform euthanasia at a patient's request under the current legislation which make these acts illegal in Germany. German history seems to play only a minor role in shaping respondents' attitudes towards active euthanasia or PAS. Eur J Gen Pract 2005;11(3):94–100.     

Character witness. Walking the talk on euthanasia

Our response to the euthanasia movement brings us to the depths of moral character and spirituality. Character bears witness to the true significance of our Catholic convictions about the dignity of persons, the value of life, our dependence on God, and our interdependence on one another. To be credible players in public debates on euthanasia and assisted suicide, we have to bear convincing witness, personally and corporately, to the ways we care first for ourselves and for those who are not as fortunate as we--the sick, the elderly, the indigent, and the dying. Who we will be in the face of death will have a lot to do with what we have come to believe about life, with the values we have upheld, with the attitudes we have taken, and with the habits of thought and behavior we have formed. So we need not be victims of what dying has in store for us. Rather, we can engage our dying by developing those habits of the heart which will make a difference in the way we adapt to unwanted circumstances and endure what we cannot change. We cannot develop strength of character if we are not nurtured by a community of character. In addition to personal character, we also need to be a community that gives witness to those fundamental religious and moral convictions which shape our living and dying in ways that would make euthanasia unthinkable.     

Autonomy-based arguments against physician-assisted suicide and euthanasia: a critique

Respect for autonomy is typically considered a key reason for allowing physician assisted suicide and euthanasia. However, several recent papers have claimed this to be grounded in a misconception of the normative relevance of autonomy. It has been argued that autonomy is properly conceived of as a value, and that this makes assisted suicide as well as euthanasia wrong, since they destroy the autonomy of the patient. This paper evaluates this line of reasoning by investigating the conception of valuable autonomy. Starting off from the current debate in end-of-life care, two different interpretations of how autonomy is valuable is discussed. According to one interpretation, autonomy is a personal prudential value, which may provide a reason why euthanasia and assisted suicide might be against a patient’s best interests. According to a second interpretation, inspired by Kantian ethics, being autonomous is unconditionally valuable, which may imply a duty to preserve autonomy. We argue that both lines of reasoning have limitations when it comes to situations relevant for end-of life care. It is concluded that neither way of reasoning can be used to show that assisted suicide or euthanasia always is impermissible.     

Chemical substances used in plastics intended for manufacture of food packaging in light of European Union legislation

In the EU countries the use of the chemical substances for plastics intended to come into contact with foodstuffs is regulated by Directive 89/109/EEC and the several specific Directives. Positive lists of the chemical substances for plastics intended to manufacturing of food packaging are placed in Directive 90/128/EEC on plastics materials. This 90/128/EEC Directive so-called "Monomer Directive" has been amended five times by Directives 92/39/EEC, 93/9/EEC, 95/3/EC, 96/11/EC and 99/91/EC. Directive 90/128/EEC so-called "Monomer Directive" provides: list of monomers and other starting substances that can be used in the manufacture of plastics materials and articles, placed in two Sections (A and B), and list of additives initiated from Directive 95/3/EC. Other additives will be added to this list on the basis of their positive national regulatory status in the EU countries and limits of migration (global, specific). According to the EU legislation all the substances before placing on the positive lists are the evaluated and authorized by the scientific bodies (SCF and/or JECFA). The EU legislation on the plastics materials and articles intended to come into contact with foodstuffs will be implemented into Polish law. However all the regulations relating to the chemical substances and limits of migration (global and specific) are already accepted by the National Institute of Hygiene.