Care of the Sick and Dying

CARE OF THE SICK AND DYING

Bishops of Maryland

A Pastoral Letter October 14, 1993

Dear brothers and sisters in Christ,

The advance of modern medicine enables us to live longer, healthier lives; great progress has been made in conquering and preventing disease. We are grateful for the life-saving treatments now available to so many people. We also recognize the challenges which come with such progress. In time of serious illness or imminent death, we are called upon to make wise choices about the means that are available to sustain life. We may need to make such decisions either for ourselves or for loved ones. These can be among the most complex and difficult decisions of our lives.

Reasons for this Letter. As bishops serving the State of Maryland, we want to reflect on these difficult choices. We do so because we know that almost every family we serve faces them. In addition, the changing health care policies at national and state levels demand that Catholics be well informed concerning sound moral principles. At the federal level, a 1991 law requires most health care facilities to inform patients of their right to indicate the kinds of treatment they would desire or would want to forego should they become incapacitated. Earlier this year, the Maryland General Assembly enacted the Health Care Decision Act, which took effect October 1,1993. Moreover, as believers and citizens, we must recognize the increasing tendency of our society to devalue human life especially the lives of those who are most vulnerable. We are called to bear witness to the value of human life.

To Whom this Letter Is Addressed. With all this in mind, we want to share with everyone the helpful and comforting guidance which the teaching of the Church offers regarding medical decisions in time of serious illness. Health care professionals have also expressed a need for sound ethical guidance as they assess various forms of treatment available to the patients they serve; we want to offer them positive and practical moral guidance in their role of service to the sick. So also families often call upon clergy to assist them when they are facing a terminal illness or imminent death; we want to be of assistance to priests and their associates in pastoral ministry in their vitally important role.

Principal Points of this Letter. We cannot, of course, provide a ready made answer for each situation; this is not the intent of this letter. Our purpose is to share with you as clearly as possible the Church's teaching on respect for human life in the context of sickness, suffering, and dying. First, we shall speak about our common duty to care for the sick, for that is the setting in which the Church's teaching is most readily understood. Next, we shall explain the principles which are at the heart of this teaching and which must guide medical decisions in time of serious illness. Then we shall show how those same principles offer guidance in cases such as imminent death or when a decision must be made with regard to some specific treatment. We also shall explain how those principles shed light on advance directives for health care, including the written or oral appointment of an agent to make health care decisions and the execution of a living will.

Church's Ministry To The Sick

The Gospels speak to us of Jesus' great concern and love for the sick. Throughout His public ministry, Jesus' Compassion and love for the sick shine through. We read how Jesus cured the sick and restored them to friendship with His Father. The Church continues Jesus' ministry of caring for the sick with deep compassion and respect for human dignity.

The Gospels also speak to us of a Savior who experienced the depth of human suffering and death itself. Jesus suffered and died for our sake in loving obedience to His heavenly Father; that is how He redeemed us: "dying, He destroyed our death; rising He restored our life." By suffering, dying and rising, the Lord gave the mystery of human suffering and death a Profound and salvific meaning. Seen in the light of Jesus' redeeming love, sickness can help believers to overcome all that separates them from God. Enduring great suffering and facing imminent death, people of faith often experience deep inner healing and reconciliation; theirs is a special witness to the love of Christ. They also can help others to open their hearts more fully to Him. To be sure, the Church teaches the importance of preserving life and prays for the health and well-being of its members. Through balanced and compassionate teaching, the Church helps us make morally sound decisions concerning the course of our health care even as it helps us prepare for death with the unwavering hope of eternal life.

The Church continues Christ's ministry to the sick and dying through the Sacraments. In offering the Sacrament of Penance, the Anointing of the Sick and Viaticum (Communion of the Sick), the priest brings to those who are ill the loving and redeeming embrace of Jesus. In these moments rich with grace, the priest, acting in the Person of Christ, brings to the patient forgiveness, inner healing and strength for what lies ahead. Together with deacons, religious, lay ministers and volunteers, the priest shares with the patient, and with the patient's family, the Good News of Jesus, the Gospel of life and salvation. Through the grace of God, patients are enabled to unite their sufferings with the Lord's so as to share His everlasting joy and glory. So also the Church reaches out to families facing the serious illnesses of loved ones with deep respect for the precious gift of life and with hope for the gift of eternal life.

Principles At The Heart Of The Church's Teaching

The principles at the heart of the Church's moral teaching on end of life decisions are important expressions of Christian reverence for the gift of human life. We believe that each person is created in God's image. By taking on our human nature, that is, by fully sharing our life, the eternal Son of God taught us how precious each human life really is in His Father's eyes. Our God in heaven knows and loves each one of us. What happens to us on this earth matters to Him. The Lord is especially close to the vulnerable and suffering. Contemplating our crucified Savior, we can regard no human life as useless or burdensome. Each person is precious in God's eyes and called to eternal life and joy.

This is the basis for the Church's teaching on the dignity of the human person and our duty to foster and sustain human life. Our faith teaches us to see human life as a precious gift from God; we are not its owners but its guardians. As such, we must oppose direct attacks on innocent human life. In that spirit, the Church proposes the following moral principles to guide our choices about medical care and treatment in time of serious illness and imminent death:

1. Our most basic God-given right is the right to life.

God's gift of human life is the foundation for all His other gifts. The most basic right of each person includes the right to preserve his or her life. The Church teaches that human life remains "the first right of the human person" and "the condition for all the others."

2. We do not have the right to take our own lives, nor directly to bring about the death of any innocent person.

Since we are stewards, not owners, of the life God has given us, we do not have the right to take our own lives either through euthanasia or willful suicide. Euthanasia is sometimes called "mercy killing". It refers to positive actions (such as injecting a lethal drug) which hasten death in order to ease extreme suffering. The term also refers to the deliberate withholding of basic care, comfort and medical treatment for the same purpose. We can readily understand how a person in prolonged agony, with no hope of recovery, might view death as a release from suffering. We also can appreciate how a family might even pray for the death of a loved one afflicted with an incurable disease. But no one must ever presume to adopt a course of action or inaction which is intended to cause death, even if the motive is to alleviate suffering. No matter how good the motives might seem, euthanasia is an attack on vulnerable human life.

The growing acceptance of euthanasia in our society is deeply disturbing. As believers and citizens we need to resist efforts to legalize euthanasia. Neither civil government nor any human authority has the right to recommend or permit euthanasia. At the same time, we also need to have a clear understanding of what distinguishes euthanasia from morally licit decisions about accepting or refusing medical treatments in time of grave illness and imminent death. The principles that follow aim to make this distinction clear.

3. Christian faith reveals the true meaning of human suffering.

We cannot be indifferent to human suffering. As believers we reach out in love to suffering persons because we see in them the image of Christ. Our faith enables us to see the suffering which serious illness entails as an opportunity to share in Christ's redemptive suffering. With the help of medical science, however, we try to bring as much comfort and relief as possible to the suffering—but never through euthanasia. Important decisions about health care should always be approached with hope and trust in the Lord who has given us the gift of life and who calls us to share eternal life in heaven.

4. Each of us is obliged to care for the gift of life and health which God has given us.

We are not free to neglect ourselves; on the contrary, we are obliged to make reasonable efforts to preserve our health and to prevent serious illness. In time of sickness, we must take sensible steps to restore our health. Such efforts often include appropriate care given by medical professionals. This does not mean that all possible remedies must be used in each circumstance. Patients and their families frequently need help in deciding which level of care is appropriate to fulfill the God-given duty of preserving life. Such complex decisions often require consultation with health care professionals and with a parish priest, hospital chaplain or others involved in pastoral ministry. Those who are sick depend upon physicians and other professionals to explain the nature of their condition and the remedies which offer some relief. Some forms of medical intervention are designed to cure diseases; others merely relieve the symptoms or retard the progress of a disease. Still others are designed to compensate for the failure of some bodily function. When patients consent to medical interventions, they expect some sort of benefit, whether a complete cure or simply temporary relief. Such medical information, however, is not enough for an informed moral decision. It is also important to apply the principles contained in the Church's teaching; to do so, it is often helpful and necessary to consult with those who are charged with faithfully sharing the Church's teaching in its fullness.

5. No patient is obliged to accept or demand useless medical interventions.

Common sense tells us that no patient is obliged to accept or demand medical care or treatments which have no beneficial effect; indeed, the application of useless medical interventions can be wasteful and detrimental to the common good. But what is a "useless" medical intervention?

A medical treatment is "useless" to a particular patient if it cannot bring about the effect for which it is designed. Such an intervention is both ineffective and medically inappropriate. For example, if a patient is given a drug to fight an infection, but subsequently the infection proves resistant to the drug, this proposed remedy is useless and need not be provided.3

A medical means or treatment should not be deemed useless, however, because it fails to achieve some goal beyond what should be expected. For example, a feeding tube is used to provide nutrients to a patient no longer capable of eating; the tube is useful when it delivers these nutrients to the patient who, in turn, absorbs them. It is useless if the patient becomes incapable of absorbing the nutrients the tube delivers. Moreover, a feeding tube should not be described as useless if the nutrients it provides are unable to cure an underlying pathology; the feeding tube should not be expected to restore the patient to consciousness or to remove any other debility not related to the need for nutrients.

Patients and their loved ones need to rely on health care professionals who can help them decide which forms of treatment are effective and, thus, useful, and those which are ineffective and, thus, useless. However, no one—including the patient, family members, medical professionals or members of the clergy—ever has the right to decide that a patient's life is useless, even when a patient is no longer able to perform basic human functions. We are stewards, not owners, of the gift of human life.

6. There is no moral obligation to employ useful but excessively burdensome medical interventions; however, the meaning of "excessively burdensome" must be properly understood.

A seriously ill patient is not necessarily obliged to employ every possible medical means, even those which promise some benefit. In many cases, there is no obligation for patients to accept interventions which impose serious risks, excessive pain, grave inconvenience, prohibitive cost, or some other extreme burden. While the most basic principles of Christian morality oblige us to preserve human life, nonetheless, individuals need not undertake excessively burdensome efforts to preserve their lives. Whether a given treatment is necessary or useful to a particular patient is a medical question requiring the expertise of health care professionals. Whether a particular treatment is excessively burdensome to an individual patient is a moral question requiring the advice of a priest or someone else well trained in sound moral theology. Individual patients and their families, health care professionals and Catholic medical facilities should actively seek the guidance of the Church in these serious matters.

A patient may reach a morally acceptable decision to forego a potentially beneficial medical treatment proposed by his or her doctor because the treatment itself is too burdensome. For example, a person may judge in good conscience that the pain and difficulty of an aggressive treatment for terminal cancer is too much to bear, and thus decide to forego that difficult treatment. Here, the ethical judgment to be made is whether the benefits of a proposed treatment warrant the significant difficulties and suffering which it may bring to a particular patient.

Conversely, it is always morally wrong to forego a potentially useful medical treatment because of a decision that one's very life is too burdensome and thus no longer worth living; such a decision opens the door to euthanasia. We should not stop medically useful interventions because we are tired of living or feel we no longer have a contribution to make. Nor can we in good conscience elect to forego a medically beneficial treatment in order to avoid the suffering which the disease itself brings. Moreover, just as we cannot licitly decide that our own lives are too burdensome to be continued, so also we cannot make such a decision regarding the life of a person for whom we may have legal responsibility.

In short, patients may morally decide that a particular form of treatment is excessively burdensome; but they may never morally decide that their very lives are so burdensome that they may forego the normal medical means of sustaining their lives. Nor may anyone ethically make such a decision for anyone else.

The Virtue Of Prudence

Good moral instruction always acknowledges the differences that exist between general principles and the application of those principles to individual lives. No general statement of principles can take into account all the particular facts and circumstances of every possible case; universal moral principles require application to particular situations. This is not to say that the principles are vague or uncertain; rather, the same principles may lead people to different courses of action in light of their particular conditions. For example, the level of care and the kind of treatment which medical professionals might provide in a hospital setting are not necessarily appropriate for someone who is receiving adequate care at home. It is important to see that in diverse settings, differing courses of action may be consistent with the same moral principles.

But what enables us to have some assurance that we are correctly applying the principles of the Church's teaching to our situation? First, we should always pray for the guidance of the Holy Spirit in seeking moral truth. In particular, we should pray for an increase of the Christian virtue of prudence. For many people, prudence simply means being cautious; but in the Catholic tradition, prudence implies much more. A gift of God's love, prudence helps the Christian in the face of moral dilemmas. Prudence is a virtue that helps us to judge rightly all the factors involved in a complex decision, to determine their relative importance and, without undue delay, to enact a sound judgment. This virtue also helps us account for the impact of such decisions not only on ourselves, but also on others, especially loved ones. In addition, prudence enables us to weigh all the factors involved in making an informed medical decision for another person. When doubt persists, the prudent person will continue to pray to the Holy Spirit and seek the counsel and advice of wise persons well trained in the teaching of the Church. In time of serious illness or imminent death, priests and their pastoral associates are often called upon to be those prudent and loving advisors.

Making Decisions for Oneself. Each of us has a tendency to defer thoughts of serious illness and death until the last possible moment. Yet, throughout our lives we need to reflect both on the dignity as well as the fragility of human life. We should prayerfully cultivate the virtue of prudence and reflect on the deep truths of our faith regarding the value of human life and our calling to life everlasting. We need to know the Church's moral teaching on the sanctity of life and understand the principles that derive from that teaching. All this is done with hope for everlasting life; the Church continues to urge us to pray for the grace of a happy death. From time to time, it is helpful to discuss these matters with a parish priest or with a spiritual director.

Clearly, we are not entirely free to do whatever we wish when we make decisions about the care of our own life and health. We are called upon prudently to preserve and protect our lives for the service of God and neighbor. When professional medical care is needed, we must consent to the reasonable use of appropriate services so that we do not neglect our own well-being. Beyond these normal efforts, we are at liberty to employ or to refuse the more advanced techniques of modern medicine which may entail excessive difficulty or risk, provided that their use does not prevent us from meeting other needs in life, such as spiritual and familial obligations. As noted above, it is morally acceptable to interrupt such treatments when they are no longer beneficial.

Making Decisions for Another. We know, of course, that some serious illnesses render it impossible for many people in our society to make or communicate decisions concerning their own medical treatment. At times we may be faced with the responsibility of making decisions for loved ones who can no longer do so. We are called upon to put ourselves in their place and to take account of their God-given obligations. Christian love calls us to be just as attentive to their needs as we would be to our own. An important part of attentiveness to the sick is making morally sound medical judgments in their stead. And sound judgments require that we prudently apply the same principles that we would use if we were making those decisions for ourselves.

While it is true that one should also take into account the attitudes and beliefs of the sick person, no one should feel compelled to act out of a misguided sense of loyalty. Let us suppose, for example, that a husband tells his wife that he would refuse any sort of treatment should he ever suffer an extreme debility. In the event that such an illness befalls him and renders him no longer able to communicate, his wife is not morally bound to honor wishes that are inconsistent with Church teaching. Rather, she is obliged to determine what sort of treatment is appropriate for her stricken husband, based on his previously stated wishes in light of current medical information and moral principles.

We also need to be alert to the difference between what civil laws permit and what is morally acceptable. It may be legal for an individual to choose a course of self-neglect; indeed, it may be legal for an individual to honor such a choice made by another. However, it remains morally wrong for a guardian to honor a patient's wishes which disregard the God-given value of human life itself. What the patient cannot do morally, another cannot do on the patient's behalf.

Impact of Burdensome Treatments on Loved Ones.

Whether we are deciding the course of our own health care or making decisions for another, we should take into account the impact which a potentially useful but burdensome treatment may have on one's family. For example, in a particular case it may be possible for a father facing grave illness prudently to decide to forego a potentially beneficial treatment if he judges that this treatment might completely impoverish his family. Indeed, the various hardships which such treatment might impose on his family can be regarded as part of the burden borne by this patient. While the economic impact of medical treatments should not be the primary consideration, neither can this aspect be ignored.

Often, however, family members are called upon to make medical decisions for loved ones who are no longer able to do so. Such family members may find themselves facing both emotional and economic hardships brought about by the prolonged illness of a loved one. In such circumstances, they may have the responsibility to decide whether to initiate or end a form of treatment involving significant burdens for a loved one. Family members serving as proxies are bound in conscience to reach such judgments carefully. For example, they must not act out of emotional distress, self-interest, or in the hope of material gain. They must put themselves in the place of the patient and consider the factors the patient rightly would have to take into account if he or she were conscious and able to direct his or her health care.

Let us return to the example of a father who is beset by a serious illness. Suppose he becomes permanently unconscious without having communicated his wishes regarding his medical treatment to his wife. Now his wife must reach an informed judgment. She is obliged to consider all the factors her husband would have considered, including his God-given obligations as a Christian believer, spouse, and parent. Among other things, she would need to consider the impact of the proposed treatment on family members. Just as parents are frequently required to sacrifice in everyday matters for the well-being of their children, so also they can be called to show that same generosity in ultimate matters of life and death.

That same spirit of sacrificial love may prompt a patient to choose advanced and aggressive treatments which do in fact impose severe burdens on him or her. For example, a patient with a rare disease may accept an experimental treatment, even though it involves great pain or grave risk, in order to help advance medical science. Or there may be compelling reasons for a parent responsible for young children to endure an extremely painful and risky treatment in the hope of surviving long enough to take care of his or her family. In these ways, too, physical suffering enables a patient to embrace a spirit of Christian sacrifice, "filling up what is lacking in the afflictions of Christ on behalf of His Body the Church" (Col. 1:24).

Imminent Death And Progressive Diseases

The general principles previously described guide decisions about medical treatment in time of serious illness—both when death is not an immediate threat and also when it is imminent. They reflect the 1980 Declaration on Euthanasia issued by the Congregation for the Doctrine of the Faith, which states: "When inevitable death is imminent in spite of the means used, it is permitted in conscience to make the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted."4

Of course, this provision does not in any way permit us to abandon the dying. While we may not be obliged to subject them to aggressive treatments, we are obliged to make them as comfortable as possible, to express our love and concern, and to pray with them and for them. Priests and their pastoral associates have a special role to play in caring for the sick as death approaches, and in comforting their families.

These same principles apply to long-term, irreversible conditions such as AIDS and Alzheimer's disease. As we shall see, the 1993 Maryland law uses the phrase "end-stage condition" to describe such progressive illnesses which sooner or later result in death. Unlike a patient in a terminal condition, a patient in an end-stage condition does not face imminent death, although the condition is "advanced, progressive, and irreversible."

And unlike a patient in a persistent vegetative state, a patient in an end-stage condition does not suffer a total loss of consciousness, although the condition may result in "severe and permanent deterioration." Patients suffering from such diseases are often especially vulnerable; it may be legal to withdraw treatment from such patients in circumstances where morally it should be maintained. Respect for their human dignity forbids any act or omission intended to end their lives.

Medically Assisted Nutrition And Hydration

Often, patients who are very near to death cannot take food and water orally. There are also long-term patients who can no longer take food and water orally. When it appears that such patients will remain unconscious for the rest of their lives, this condition is called a "persistent vegetative state." Such patients may or may not be facing imminent death; in any case, they remain incapable of human communication. Are those responsible for such patients obliged to continue medically assisted feeding and hydration?

No one can provide a universal answer to that question, appropriate for all possible cases. However, there is a clear presumption in favor of supplying food and fluid to such patients. Moreover, the principles we have already discussed offer sound guidance to those who must face decisions with respect to medically assisted feeding and hydration. These principles first tell us that, because human life is a precious gift of God, we use medical interventions to preserve it. Again, there is no reason to employ useless measures or measures which impose excessive hardship on the patient. In particular cases, good moral decisions can ordinarily be made only when one sees how a given intervention will affect an individual patient. One can only determine what is useful or useless for the patient in the light of specific, clinical facts which may indicate the imminence of death or the presence of a medical condition that renders medically assisted feeding and hydration useless. Lack of consciousness alone does not indicate that medically assisted feeding and hydration is useless. Thus medical expertise reveals the pertinent clinical facts; but the Church's moral expertise ensures decisions that respect human life, as coming from God and destined for His honor and glory.

We consider it both morally and medically inappropriate to make a universal statement that medically assisted nutrition and hydration must be given to all who cannot feed themselves. Likewise, it is misleading to make a universal statement that all debilitated persons not in immediate danger of death should not be provided with medically assisted nutrition and hydration. Rather, the prudent course of action is to consider the facts of a particular case and to determine whether a patient's need for nourishment and fluid can be met effectively through a medical intervention whose use does not impose excessive burdens on the patient. Patients or their proxies should choose medically assisted nutrition and hydration except when it is useless or when, having sought good counsel, they judge it excessively burdensome to the patient; the presumption, however, is always in favor of providing nutrition and hydration. This presumption recognizes that denial of nutrition and hydration can itself add to the suffering of a patient and cause death independently of the underlying pathology. No one may ever decide in good conscience to withhold medically assisted nutrition and hydration from persistently unconscious patients because their lives are deemed too burdensome or of too low a quality to be maintained. When death is imminent and medically assisted nutrition and hydration are no longer useful, normal and loving care should always be provided.

"Do Not Resuscitate" Directives

"Do Not Resuscitate" directives (DNR) are an increasingly common feature of advance health care directives. By means of a DNR, medical personnel are instructed not to restore heart functioning and breathing (CPR) after these have stopped. What guidance do the principles already described offer us with respect to DNR directives?

The decision of whether or not to resuscitate should be based on the patient's actual medical condition. Though a DNR may be justifiable at times, it often can be inappropriate for individuals to stipulate in advance that they are not to be resuscitated under any circumstances. In fact, the licitness of a DNR instruction hinges on answers to these important questions:

1. Is resuscitation a medically useful intervention? For example, CPR is clearly appropriate in the case of a sudden heart attack or during surgery which was expected to benefit the patient.

2. Is resuscitation futile? CPR may well be futile in the last stages of a terminal illness when death will soon follow no matter what means are used.

3. Is resuscitation unduly burdensome to the patient? For example, would it procure only a precarious, short term survival? At the same time, there can be special reasons why a patient may want to endure extremely burdensome treatment in order to survive for a longer period of time, for instance, to settle personal affairs or to seek the last sacraments.

It is difficult for many to predict the answers to such questions prior to an actual medical crisis. Often, the varying factors which must be accounted for do not really become clear until medical personnel can assess firsthand the patient's condition and determine what results would follow if a patient were revived. A DNR directive, however, may well be appropriate in cases where it is known in advance that resuscitation will secure only a short-term, precarious and burdensome prolongation of life.5 A written living will can attempt to provide for various contingencies; more likely a properly chosen and well-informed proxy will be in a better position to reach an appropriate, morally informed decision.

Maryland Law-Health Care Decision Act

We need to be familiar with the complex provisions of the 1993 Health Care Decision Act so we can make prudent, morally sound decisions with respect to health care. The preamble to the new law states: "the societal value that the life of every individual has worth in and of itself and is not to be devalued by reason of an individual's incapacity or perceived diminished quality of life...." Additionally, the new law reaffirms already existing prohibitions against mercy killing and euthanasia. At the same time, however, it allows for decisions which may or may not be morally appropriate. Again, prudent discernment is always necessary.

The main provisions of the law include:

Advance Directives—Maryland law provides for three types of advance directives.

1. A written appointment of a health care agent to make health care decisions for the patient (sometimes referred to as a "durable power of attorney for health care") and/or written instructions regarding one's future health care decisions;

2. Written instructions authorizing the provision, withholding, or withdrawal of life-sustaining procedures if the patient is in a terminal condition and death is imminent, or if the patient is in a persistent vegetative state (commonly called a "living will");

3. An oral statement to a physician made in the presence of a witness leaving instructions regarding care, or appointing an agent.

Surrogate Decision Making

For a patient who has not appointed a health care agent or executed a living will, a surrogate (guardian, spouse, adult child, parents of the patient, adult brother or sister) may make decisions about health care. The law stipulates that such decisions are to be based on the wishes of the patient, if known, or in the patient's "best interest."

"Do Not Resuscitate" Directives

In the case of an emergency, health care providers are authorized to follow a "Do Not Resuscitate" directive in an outpatient setting.

Court Appointed Guardian

A court can empower guardians to use their own best judgement to make decisions about life-sustaining treatments in certain circumstances:

1. When there exists an advanced directive which

authorizes such a decision;

2. When the guardian is the disabled person's spouse, adult child, parent, or adult brother or sister, and is acting in his or her surrogate status.

Substituted Judgement

The court may make a "substituted judgment" on the basis of clear and convincing evidence that the disabled person would, if competent, decide to withhold or withdraw a life-sustaining procedure, or if the court determines on the basis of clear and convincing evidence that the withholding or withdrawing of a life sustaining procedure is in the patient's best interest.

Preparing Advance Directives

The Church's teaching on the sacredness of life governs all decisions concerning the preservation and care of life from conception until death. Whether one makes decisions for oneself or for another person who is incapacitated, every Catholic is obligated to act in accord with Church teaching. In view of the provisions of the Health Care Decision Act and in light of the principles contained in the Church's teaching, we wish to offer the following information and guidance with respect to the preparation of advance health care directives.

Advance directives are legal documents through which individuals guide the course of their own medical treatment even after they can no longer make decisions or inform others of their desires. For instance, an advance directive can be prepared by which the patient (called the principal) delegates someone else (called the agent) to make health care decisions in the event that the patient (the principal) can no longer make such decisions personally. A living will is another advance directive that enables adults to declare in writing their desire to refuse specific life-sustaining procedures when they can no longer make their own decisions because their death is imminent from terminal illness, or because they are in a persistent vegetative state.

Maryland law offers several legally permissible advance directive models which may be offered to you at some health care institutions and by some physicians and attorneys. Some of them may permit authorization of actions that do not respect the God-given value of human life as the Church instructs us. Thus, we should use great caution in choosing any standardized directive. It is important for you to know its provisions well and to determine whether or not the directive allows for morally sound medical judgments to be made in time of serious illness. All advance directives require such scrutiny.

Maryland law stipulates criteria for drawing up advance directives. If those criteria are met, medical professionals may rely on such directives without fear of liability. It is possible, however, that a particular physician or health care facility may refuse to comply with a particular directive for reasons of conscience. In that event, the designated agent (or proxy) may seek a physician or health care facility willing to honor the provisions of the directive. It is not difficult to revoke an advance directive, and revisions may be made in writing or by an oral statement to a health care practitioner, or by executing an entirely new directive which replaces the previous one.

Appointing a Health Care Agent. Under Maryland law, a patient may appoint a health care agent to make decisions in the event that the patient can no longer do so. The appointment can be made orally, or in a written document. Is it wise to give such authority to another? Again, it is impossible to give an answer that is right for everyone. In most cases, however, the written appointment of a health care agent is preferable to a living will or to an oral directive. Let us look at some of the advantages to the prior written appointment of an agent and then consider some practical guidance for drawing up such a document.

The chief advantage of appointing a health care agent is that it leaves decision making in the hands of a person of your own choosing. In the event you are no longer able to communicate your wishes, you can empower a reliable person (agent) to discuss your present medical situation and available treatments with your doctor. Your agent can then reach an informed decision, based on current medical facts and sound moral principles, in keeping with the Church's teaching. The agent has the legal authority to consent to or refuse medical treatment on your behalf. Please note, however, that you can also restrict the scope of the authority of your agent, should you deem it best to do so.

It is important to know that the Maryland law authorizes "surrogate decision making" for a patient who has not appointed a health care agent or executed a living will. This law allows the surrogate to make health care decisions; it stipulates that such decisions are to be made on the known wishes of the patient, or in the patient's "best interest" if his or her wishes are not known. Obviously, there is no guarantee that a surrogate will make such decisions in accord with the Church's teaching. It is therefore wise to appoint an agent in advance whom you can trust to make morally sound medical decisions on your behalf.

Criteria for Health Care Agents. If you choose to appoint an agent, you may want to consider the following points:

—You should appoint someone who has the strength of character to make good judgments in painful circumstances.

—You should appoint someone whom you know you can trust to make decisions on the basis of the Church's teaching. The prudent person will select an agent who will act as he or she would have acted in whatever circumstances evolve.

—No one should agree to act as an agent for another person if that person would expect or require the agent to make decisions which disregard the teaching of the Church. It is not morally acceptable to carry out immoral decisions on behalf of someone else. No agent and no physician should ever feel obliged to act contrary to their well-formed consciences, even on behalf of another person.

—You should appoint someone who is likely to be available to care for you in the distant future. The law implies that only one agent need be designated; it may be advisable, however, to name alternate agents, in the event that your first choice proves unable or unwilling to act for you when the need arises.

—Discuss the specifics of your directive with the person whom you wish to choose as your agent. You also are well advised to discuss these specifics with your physician. You also should discuss them with an attorney to ensure that they meet the requirements of the law.

You should generally avoid:

1. stating that you wish to reject certain treatments under all circumstances, except in the case of imminent death or when one's present medical condition makes it clear in advance that such treatments would be futile;

2. stating without qualification that you want medical remedies restricted in the event that you become permanently unconscious or terminally ill. Such stipulations can amount to providing a premature self-diagnosis. You should allow your agent and physician latitude to offer you appropriate care based on your actual condition.

—You should include a provision regarding treatment at the time of imminent death. Recall that the Church allows a person on the verge of death to refuse treatment which would result only in a burdensome prolongation of life. Your advance directive should authorize your agent to observe this norm. Such an authorization will bring much comfort to your loved ones in a time of emotional stress; it is also an expression of your profound Christian hope in the life to come.

—You should periodically review the provisions of your advance directive. After discussions with your agent, priest, physician, and other appropriate persons, you may want to revise or renew the document to ensure that it accurately states your wishes.

—You should make copies of your directive and distribute them to your agent, your physician and anyone else you deem appropriate. Should you decide to revise your directive or replace it with another, be sure that all obsolete versions are destroyed.

Living Will. A living will is a written instruction you can prepare to provide for your own medical treatment at the end of life when you are no longer able to make decisions for yourself. A living will document, as regulated by the Health Care Decision Act, enables an individual to make decisions in advance about the delivery of life-sustaining procedures if the individual's death from a terminal condition is imminent, or the individual is in a permanently unconscious state (persistent vegetative state).

The Health Care Decision Act offers an optional form for the execution of a living will. It allows the declarant to give specific instructions in the case of pregnancy and to select from three options:

1. no provision of life-sustaining procedures, including medically administered nutrition and hydration;

2. no provision of life-sustaining procedures, except for the administration of nutrition and hydration;

3. provision of all available medical treatment in accordance with accepted health care standards.

As stated previously, it is definitely preferable to appoint a prudent health care agent who will follow Church teaching rather than to draw up a living will. Often it is difficult to predict what one's actual medical condition will be when decisions will have to be made with respect to medical treatments. A Living will, nonetheless, may be of assistance in particular circumstances; for example, it may be appropriate for someone who, for whatever reason, is unable to appoint a health care agent or for someone on the verge of a final illness to execute a living will. Care should be taken that a living will not become a means of refusing a morally required treatment or of removing prematurely some life-sustaining procedure.

Oral Directives.

Maryland law allows the patient to give an oral statement to his or her physician, either leaving instructions about the course of his or her health care or appointing an agent. The law stipulates that such a statement must be made to a physician and be witnessed by one other individual. The directive is to be recorded in the patient's medical record and signed and dated by the physician and the witness.

Usually, an oral directive is made when one is facing a serious medical problem without an advance written directive, or when an individual for some reason finds it difficult to prepare a written directive. Patients who elect to make an oral declaration should exercise the same prudent judgment as those preparing a written advance directive-either to appoint an agent or to direct the course of their own health care. No one should make an oral directive without proper forethought, wise counsel and an awareness of the consequences of such important decisions. The patient must exercise much care to ensure that the physician and witness have truly understood his or her wishes. In general, written directives appointing a responsible agent are preferable.

Conclusion.

As bishops serving the State of Maryland, we offer these reflections at a time when all of us are strongly challenged to witness to the worth and dignity of human life. We believe our pastoral concern is best expressed by offering compassionate guidance for decision making in keeping with the wise and loving teaching of the Church. We are convinced that this teaching reflects the wisdom and love of God, the Author and loving Sustainer of all life.

As believers, we do not deny the reality of suffering or despair at the approach of death. Faith in Christ eases the pain of human separation and anxiety over our mortality. For we are daily challenged to listen to the words of St. Paul: "Set your minds on things that are above, not on the things that are on the earth. For you have died, and your life is hidden with Christ in God" (Col. 3:2-3). We know that Jesus, the Bridegroom, is coming for each of us at the hour of His choosing. We await and prepare for His arrival, not in fear, but full of expectant hope. We are confident that at His gentle approach every tear will be wiped away by the One who has conquered sin and death and made us heirs to eternal glory.

Notes

l See, "Nutrition and Hydration: Moral Pastoral Reflections,

" NCCB Committee on Pro-Life Activities, April 1992, pp. 3-6. The precis found in that NCCB document is the basis for the summary presented here.

2 Congregation for the Doctrine of the Faith, Declaration on Procured Abortion (1974), para. 11; see also Nutrition and Hydration, op. cit., p.3.

3 Throughout this pastoral statement case examples are cited in the interest of concretizing the principles enunciated here. However, the solutions given in these cases are not meant to be followed by everyone in similar situations; they are merely meant to illustrate the legitimate application of the principles in a particular set of circumstances. In a case dealing with medical ethics, we must first make certain that we know the medical facts of the case. We must then make certain that we have done every good thing we are required to do. We must also ensure that we avoid intrinsically evil actions such as suicide or euthanasia. Beyond these considerations lies a rather large area of actions which may be taken, but which are not required in all particular cases. It is within this realm of options that many of the cases of which we speak are decided.

4 Declaration on Euthanasia, Part IV.

5 Declaration on Euthanasia. Part IV.

Most Rev. William H. Keeler Archbishop of Baltimore Chairman
His Eminence James Cardinal Hickey Archbishop of Washington
Most Rev. Robert E. Mulvee Bishop of Wilmington
Most Rev. Alvaro Corrada
Auxiliary Bishop of Washington
Most Rev. William G. Curlin
Auxiliary Bishop of Washington
Most Rev. P. Francis Murphy
Auxiliary Bishop of Baltimore
Most Rev. William C. Newman Auxiliary Bishop of Baltimore
Most Rev. Leonard J. Olivier Auxiliary Bishop of Washington
Most. Rev. John H. Ricard Auxiliary Bishop of Baltimore