In my previous brief, we focused on providing palliative care, when curing is not possible. Today, we continue our discussion with the promised focus on proportionality. First, however, we should review a few terms:
- Euthanasia is when one person brings about the death of another, either through a positive act or the omission of necessary attention and care. It is always a form of homicide and thus is never permissible.
- Dysthanasia (overzealous therapy or therapeutic obstinacy) is the opposite of euthanasia and consists in delaying death as long as possible, using every possible means, even though there is no hope for a cure and despite the great suffering caused by treatment.
It is important to note that causing death (euthanasia) is not the same as permitting death and accepting the natural end of life (avoiding therapeutic obstinacy).
- Basic care consists of four elements: nutrition, hydration (even administered through artificial means), cleaning (especially of bedsores) and ensuring a permeable airway. This care cannot be refused or it becomes a case of passive euthanasia.
The historical terms “ordinary care (or means)” and “extraordinary care (or means)” are no longer in use as rapid improvements in medical care make it increasingly difficult to distinguish between the two. Yesterday’s extraordinary care might be quite ordinary today. Thus, it is preferred to speak of “proportional care” and “disproportional care,” evaluated according to the results obtained from the care.
Judgment Of Proportionality
Proportionality is the evaluation of the relative benefits and costs (not simply economic) of various treatment alternatives.
Family members, or, if possible, the patient, should ask the doctor to what extent it is worthwhile to perform a certain therapeutic intervention. In objectively analyzing the costs to the patient (suffering, confinement, pain, adverse effects) compared to the benefits (improvement, healing, feeling better), the question is: Is treatment worthwhile given the patient’s physical and moral strength?
- If the benefit is greater than the cost, the intervention is proportional and I am obliged to give it. Withholding treatment would be a case of passive euthanasia.
- If the cost is greater than the benefit, the intervention is disproportional and I am not obliged to give it. By forgoing treatment, dysthanasia is avoided. Refusing the intervention is just; the patient will die of his illness without prolonging his agony.
To reiterate, basic care can never be subjected to an evaluation of proportionality since the patient should always receive it; it is due the patient. Care beyond basic care can be submitted to an evaluation of proportionality in order to determine if one is obligated to give it or not. Further, care and treatments that are possible and available should not be denied when they are known to be effective, even if only partially.
In the evaluation of proportionality, objective elements (the medical data) and subjective aspects that involve the particular patient—how much I am suffering and why I want to live longer—must be considered.
We offer these very useful criteria:
- In the absence of other remedies, and with the consent of the patient, it is licit to accept treatments that are still under experimentation and imply certain risks.
- It is also licit to interrupt such interventions when results do not measure up to expectations and the treatment becomes objectively disproportionate. In making this decision, the just desires of the patient and his family should be taken into account, as should the opinion of truly competent medical professionals.
- It is always licit to settle for the proportional means that medicine has to offer. Thus, no one can be forced to accept treatment, even treatments readily available, that are disproportionate, very costly, or not possible to administer.
- When death is imminent, despite the interventions being administered, it is licit to renounce treatments that bring an unstable and painful prolongation of life, though without interrupting basic care.
- Renouncing extraordinary or disproportionate means is not equivalent to suicide or euthanasia. Instead, it expresses an acceptance of the human condition faced with death.
It must not be forgotten that the patient is always due the truth. To lie is incorrect, and besides, it creates a communication barrier. If the family lies to the patient (even if seeking his good), the patient will not have the impetus to express what he is feeling, say good-bye to his loved ones and prepare himself spiritually and humanly. It is important to determine who will speak to the patient and in what manner. The truth can be spoken progressively, revealing only as much as the patient needs to know.
It is very important that family, especially, and also doctors and nurses, accompany the patient humanly and spiritually, until his final breath. Furthermore, it is important to help the patient and the family to give meaning to suffering, that is, to change the question from “Why?” to “For what purpose?”
For consultation with Dr. Calva, feel free to contact her at firstname.lastname@example.org