Academic journal article Theological Studies

Ordinary and Extraordinary Treatments: When Does Quality of Life Count?

Academic journal article Theological Studies

Ordinary and Extraordinary Treatments: When Does Quality of Life Count?

Article excerpt

KEVIN WILDES has argued in a recent note that the distinction between ordinary and extraordinary treatments involves judgments about quality of life, that some recent statements by Roman Catholic bishops have failed to see this, and that, as a result, their judgments about feeding and hydrating patients in a persistent vegetative state have been flawed.(1) Wildes is correct, I believe, when he says that choices patients make about their own treatment involve judgments about quality of life, but he fails to take account of the substantially different moral situation that arises when others make treatment decisions for incapacitated patients. Once we see this, we may be considerably more sympathetic than he is to those episcopal statements that are critical of decisions to deny food and water to patients in a persistent vegetative state.

The basic distinction between ordinary and extraordinary treatments is nicely expressed by Wildes in a summary statement: "A treatment is morally obligatory if and only if it offers a benefit and does not impose burden. Neither condition is sufficient by itself."(2) Putting it in terms of what is nonobligatory, we can say that a treatment may be refused if it is either useless or burdensome. Both of these judgments are relative to the condition of a particular patient at a particular point in time. What is useless treatment for one patient may be useful for another; what was once useful treatment for a patient may cease to be so when progression of the disease has made a marked change in his or her condition. A burden that one person considers too great to bear may not seem unbearable to another. Thus, we can rightly say, as Wildes does, that deciding to refuse a treatment is not necessarily deciding to end one's life. It may, rather, be a decision about how to live. Of the several life choices available to patients, they may choose a life that is shorter but relatively less burdened by treatments. But still, they choose life. Nor is there any need to object to Wildes's desire to characterize such choices as "quality of life" choices. Several life choices are available. The character and duration of these lives differ in various ways which might reasonably affect a person's preference for one or another. And from these the patient chooses one that will be his or her life.

So far so good. What Wildes does not explore, however, is how best to characterize such choices made by patients. Insofar as he occasionally turns to the language of "proportionate or disproportionate" treatments and the language of "weighing" burdens and benefits, he uses a metaphor that may deceive us. Patients making such choices may consider the importance to themselves of personal aspirations still unrealized, the burden and expense of proposed treatments, their responsibilities to others--and countless other factors significant in their lives. But these competing factors are not being "weighed," for they are incommensurable, and the scale on which they could be weighed does not exist. In short, when such patients choose to accept or refuse treatment, they are not making a discovery about some single right choice to make in their circumstances. Precisely because these determinations are, as Wildes underscores, patient-relative, such patients are making a decision. The patient determines, within the limits available, his or her being. Two people similarly situated may make different decisions; yet both may be choices of life. He chooses a life that is shorter but relatively free of painful treatments. She chooses a life that is somewhat longer but more painful. Neither makes a discovery about what everyone in similar circumstances must choose or even about what he or she must choose. Both make decisions about who they will be. Or, if we insist on using the language of "discovery" and "weighing," we must mean that the relative weight of the conflicting goods is known--and known only for the person deciding--after the decision has been made. …

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