CRmCAL CHOICES AND CRmCAL CARE Philosophy and Medicine 51 Editors H. T. Engei~1lIfdt, Jr., Baylor College ofM edicine, Houston, Texas S. F. Spieker, Baylor College ofM edicine, Houston, Texas CATHOLIC STUDIES IN BIOETHICS 2 Founding Editors Francese Abel, SJ., Institut Borja de Bioethica, Barcelona, Spain John C. Harvey, Center for Clinical Bioethics, Georgetown University, Washington, D.C. Series Editor Kevin Wm. Wildes, SJ., Department ofP hilosophy and The Kennedy Institute ofE thics, Georgetown University Advisory Board Paolo Cattorini, Istituto Scientifico, Milan, Italy Bernard Hoose, Heythrop College, University ofL andon, London, UK Johannes Huber, University ofV ienna, Vienna, Austria James F. Keenan, SJ., Weston School of Theology, Cambridge, Massachusetts James 1. McCartney, O.S.A., Villanova University, Villanova, Pennsylvania Jean Porter, University ofN otre Dame, Notre Dame, Indiana Paul J.M. van Tongeren, Catholic University, Nijmegen, The Netherlands CRITICAL CHOICES AND CRITICAL CARE Catholic Perspectives on Allocating Resources in Intensive Care M edicine Edited by KEVIN Wrn. WILDES, SJ. Assistant Professor ofP hilosophy, Senior Research Scholar of the Kennedy Institute of Ethics and Center for Clinical Bioethics, Georgetown University, Washington D.C., U.S.A. SPRINGER SCIENCE+BUSINESS MEDIA, B.V. Library of Congress Cataloging in PubUcation Data Critical cholces and crltical care : Catholic perspectives on allocatlng resources 1n 1ntens1ve care medlclne / edlted by Kevln Wm. Wi ldes. p. cm. -- (Phl1osophy and medlcine ; v. 51. Cathol1c studles in bioeth1cs ; v. 2) Includes index. ISBN 978-0-7923-3701-0 ISBN 978-94-011-0259-9 (eBook) DOI 10.1007/978-94-011-0259-9 1. Cr1t1cal ca re med1c1ne--Rel1g1ous aspects--Cathol1c Church. I. W1ldes. Kevin Wm. (Kevln Wl111am). 1954- 11. Serles: Phl1osophy and medlclne ; v. 51. !Ir. Serles: Phl1osophy and medlclne. Cathol1c studles In bloethlcs ; v. 2. RC86.95.C75 1995 241· .6424·08822--dc20 95-1907 ISBN 978-0-7923-3701-0 Printed on acid-free paper All Rights Reserved @1995 Springer Science+Business Media Dordrecht Originally published by Kluwer Academic Publishers in 1995 Softcover reprint ofthe hardcover 1st edition 1995 No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission from the copyright owner. TABLE OF CONTENTS Preface vii K. Wm. WILDES, S.J. / The Moral Paradox of Critical Care Medicine 1 PART ONE: CLINICAL QUESTIONS B.A. BRODY / Ethical Issues Raised by Intensive Care 7 M.A. RIB / Ethical Issues in Intensive Care: Criteria for Treatment Within the Creation of a Health Insurance Morality 23 M.A. SANCHEZ-GONZALEZ / Commentary on: Brody & Rie 57 A. SERANI-MERLO and P. ROSSO / Intensive Care: Its Nature and Problems 63 H.H. DELOOZ / Ethical Issues in Critical Care: Criteria for Treatment 79 PART TWO: MORAL REFLECTIONS ON THE CLINIC K.Wm. WILDES, S.J. / Conserving Life and Conserving Means: Lead Us Not Into Temptation 105 D. GRACIA / The Old and the New In the Doctrine of the Ordinary and the Extraordinary Means 119 P.T. SCHOTSMANS / Admission to and Removal From Intensive Care: A Personalist Approach 127 T.R. KOPFENSTEINER / The Notion of Criterion in Critical Care Ethics 145 M. CATHLEEN KAVENY / Distributive Justice in the Era of the Benefit Package: The Dispute Over the Oregon Basic Health Services Act 163 v vi TABLE OF CONTENTS PART THREE: APPENDICES Appendix A. Pope Pius Xli / The Prolongation of Life 189 Appendix B. Congregation for the Doctrine of the Faith / Declaration on Euthanasia 197 Appendix C. Society of Critical Care Medicine Ethics Committee / Consensus Statement on the Triage of Critically TIl Patients 205 Notes on Contributors 215 Index 217 PREFACE The genesis of this book was an on-going conversation between Catholic and non-Catholic physicians, philosophers, and theologians. However, substantive conversations rarely "just happen". They need support and attention. The Steering Committee on Bioethics of the International Federation of Catholic Universities, with generous foundational sup port, has given this conversation the attention and support it so needed. Begun in 1981 the Steering Committee, under the leadership of Francesc Abel, S.J. and John Collins Harvey has fostered numerous conversations for Catholic thinkers on issues in bioethics. This particular conversa tion, on the moral questions of intensive care medicine, could not have happened without their leadership. They were supported in their work by Lisa Cahill, L.BJ. Stuyt, and Robert Cefalo. H. T. Engelhardt, Jr. was invaluable to the conversation in both his leadership in its planning and his substantive participation. Francesc Abel, S.J. was vital to the project in his participation and in providing a place - an atmosphere - in which the group could meet, discuss, argue, and explore ideas. The final form of this conversation on moral issues in critical care medicine has taken shape in this book. I am grateful to the authors for their work in preparing their manuscripts and for their patience with me. A special note of thanks is due to Angela Jacobson and Charlene Brown for their help and patience in preparing this manuscript. The International Federation of Catholic Universities has reorganized the Bioethics Group and made it part of the Association of Catholic Med ical Schools. This change insures that there will be continuing interdis ciplinary work and reflection by Catholic scholars and institutions in the area of bioethics. It is our hope that these reflections will continue to develop as a body of literature that nourishes practitioners, theologians, and philosophers throughout the world. Kevin Wm. Wildes, SJ. Georgetown University Washington, D.C. K. Wm. Wildes (ed.), Critical Choices and Critical Care, vii. © 1995 Kluwer Academic Publishers. KEVIN WM. WILDES, S.J. THE MORAL PARADOX OF CRITICAL CARE MEDICINE Contemporary medicine is practiced in a paradox. On the one hand medicine offers seemingly infinite possibilities for sustaining and improving human existence. Debilitating diseases can be identified and cured. Organs can be transplanted and the lives of a recipients trans formed. Childless couples can now have children. Each day genetic studies increase our understanding of diseases and offer the hope of eventual cure. With the development of medical support for major organ systems it seems that death can be postponed indefinitely. Modem med ical practice appears to have no boundaries. Yet, on the other hand, the practice of medicine is constrained by limits. There are limits to our lives. We will all die. There are limits to our knowledge. We do not always know why a patient is ill, how the patient can be cured, or why a patient becomes better. And there are limits to our resources. We do not have the resources, in personnel, time, or money, to do everything that can be done for each patient. Each decision to do good for a patient is an implicit choice not to do something for someone else. As we become aware of the limits of our resources we can understand the relationship between choices made in the clinic and the impact on social policy. The choices made in the clinic not only affect the patient who is treated but such decisions also affect other, anonymous, patients who will be treated less aggressively or, perhaps, not at all. At the same time the choices made in the arena of social policy influence the range of choices that are possible in the clinic. The paradox then is that while medicine seems to offer infinite possibilities the practice of medicine is governed by limits. No other area of medicine highlights this paradox more clearly than critical care medicine. One has only to consider the three following realities. First, patients admitted to Intensive Care Units tend to be among those who are sickest and in need of the most help. They are often confronting their own deaths. Second, to give these patients the type of support they need intensive care units require vast resources. For example, it is estimated that in the United States one percent (1 %) of the K. Wm. Wildes (ed.), Critical Choices and Critical Care, 1-4. © 1995 Kluwer Academic Publishers. 2 K. WM. WILDES, S.1. Gross Domestic Product is spent annually on intensive care units. The decision to dedicate resources to such units is also an implicit decision to limit resources in other areas of medicine. Finally, like other areas of medicine, critical care confronts us with the limits of our medical knowledge. Critical care medicine reminds us that our knowledge is statistically based. Choices are made without the comfort of certitude. While intensive care medicine can support life infinitely it is practiced in the context of limits. This paradox of medicine's possibilities and limits is the context for difficult moral questions. Faced with the possibility and hope to do good we must decide how to act when we cannot do everything that is good. Critical care medicine provides a point of focus for such moral reflection. The moral dilemmas confronted in critical care medicine are posed by our finitude. That is, we are limited creatures with limited resources. We must make choices among competing goods. The confrontation with finitude is a deeply Christian theme. Christians understand themselves as creatures dependent on a loving Creator. This Creator has given men and women life and the gifts of creation. These lives and resources are ours to steward. With an understanding of finitude and stewardship Christianity brings a rich tradition of spiritual and moral reflection to bear on the moral questions in critical care medicine. The themes and questions of finitude have been a central part of Roman Catholic moral theology (Cronin). In both theological reflection and pastoral practice the Church has confronted the obligation to do good in a world where not all goods can be done. Catholic physicians, patients, and their families have struggled with these moral quandaries in the practice of medicine while theologians, chaplains, and bishops have sought to understand and articulate the obligation to prolong life and the obligation to provide health care for all men and women. This book is an attempt to bring together the moral questions of inten sive care medicine with Roman Catholic reflections on the obligations to prolong life and to provide health care for all men and women. The conclusions that can be learned from critical care medicine will provide helpful insights in other areas of medical practice and the formula tion of health policy. This book comes from an on-going conversation among its authors with the hope of inviting others into the conversa tion. Physicians, theologians, and philosophers have taken up the moral questions posed by the practice of critical care medicine with the hope of addressing the questions of the clinic as well as those of social policy. THE MORAL PARADOX OF CRITICAL CARE MEDICINE 3 Critical care medicine has opened new horizons for both healing and dying. The techniques and practice of critical care medicine have allowed surgeons to explore procedures that would not be possible with out the recovery support made possible by intensive care. The essays in the first section of this book explore the historical development and practice of critical care medicine and the moral questions it raises. These essays set out the background for the moral questions surrounding inten sive care medicine and decisions at the end of life. As Baruch Brody's essay makes clear the advancement of many medical techniques can be tied to the development and use of critical care medicine. Intensive care medicine provides necessary support for other areas of medical inter vention (e.g. cardiac surgery). However, because of the vast resources required in the practice of critical care medicine there are moral ques tions about its use. Brody looks at questions about admission, discharge, and the role of the physician. Who should be admitted to such units? Who should be excluded? What are the criteria that should guide us in such decisions? How much should a society devote to critical care medicine? The essays by Herman Delooz, Pedro Rosso and Alejandro Serani-Merlo illustrate how the practice of critical care medicine, and its moral problems, transcend national boundaries and have influenced the practice of medicine globally. Michael Rie argues in his essay that the use of critical care medicine is a social question as well as a clin ical question. Since critical care medicine consumes great amounts of resources it also leads to other questions about how we are deploying the limited resources at our disposal. The essays in the second section of the book bring different aspects of Roman Catholic Christian theology to bear on understanding and resolving these questions. Since the medical advances of the sixteenth century the Roman Catholic Christian community has struggled with questions, in medicine, about the obligation of patients to purse treat ment. Within its moral framework Christianity has understood human life as a basic good to be preserved. While the proscription against tak ing human life is clear in Christian thought, the question that emerged in the sixteenth century concerned the extent to which one must pursue medical treatment in order to preserve life. If there is an obligation to preserve life, must that obligation be pursued at all costs? In devel oping the distinction between ordinary and extraordinary means the Catholic community has sought to come to terms with these questions. The essays by Kevin Wildes and Diego Gracia set out the historical and systematic development of this tradition. The essay by Paul Schotsmans moves beyond the traditional framework of ordinary and extraordinary