Life-extending treatments

Terri Schiavo passed her 15th year last Friday in what doctors call an awake but unthinking state, unaware of the latest melodrama swirling around her hospital bed in Pinellas Park, Florida. Patients in such a state have lived for up to thirty-five years.

When does one end life-extending treatment for such patients? And who gets to decide?

The question of what to do with patients in a persistent vegetative state is difficult, but important. Life is full of difficult decisions, but decisions that must be made nonetheless. We cannot usefully discuss this difficult case, however, without first getting clear more generally on the morality of withholding or withdrawing treatment.

Our civilization’s received medical tradition says that we should never aim at the death of a sick or dying person. Still, there are times when treatment may rightly be withheld or withdrawn, even though the patient may then die more quickly than would otherwise have been the case. How can that be? How can it be that, as a result of our decision, the patient dies more quickly, yet we do not aim at his death?

This is quite possible—and permissible—so long as we aim to dispense with the treatment, not the life. No one need live in a way that seeks to ensure the longest possible life. (Were that a moral requirement, think of all the careers that would have to be prohibited.) There may be many circumstances in which we foresee that decisions we make may shorten our life, but we do not suppose that in so deciding we are aiming at death or formulating a plan of action that deliberately embraces death as a good. So in medical treatment decisions the question we need to answer is this: Under what circumstances may we rightly refuse a life-prolonging treatment without supposing that, in making this decision, we are doing the forbidden deed of choosing or aiming at death?

The answer of our medical-moral tradition has been the following: we may refuse treatments that are either useless or excessively burdensome. In doing so, we choose not death, but one among several possible lives open to us. We do not choose to die, but, rather, how to live, even if while dying, even if a shorter life than some other lives that are still available for our choosing. What we take aim at then, what we refuse, is not life but treatment—treatment that is either useless for a particular patient or excessively burdensome for that patient. Especially for patients who are irretrievably into the dying process, almost all treatments will have become useless. In refusing them, one is not choosing death but choosing life without a now useless form of treatment. But even for patients who are not near death, who might live for a considerably longer time, excessively burdensome treatments may also be refused. Here again, one takes aim at the burdensome treatment, not at life. One person may choose a life that is longer but carries with it considerable burden of treatment. Another may choose a life that is shorter but carries with it less burden of treatment. Each, however, chooses life. Neither aims at death.

It is essential to emphasize that these criteria refer to treatments, not to lives. We may rightly reject a treatment that is useless. But if I decide not to treat because I think a person’s life is useless, then I am taking aim not at the treatment but at the life. Rather than asking, “What if anything can I do that will benefit the life this patient has?” I am asking, “Is it a benefit to have such a life?” If the latter is my question, and if I decide not to treat, it should be clear that it is the life at which I take aim.

Against that background, we can consider the use of feeding tubes for patients in a persistent vegetative state. Is the treatment useless? Not, let us be clear, is the life a useless one to have, but is the treatment useless? feeding may preserve for years the life of this living human being. Are we certain we want to call that useless? We are, of course, tempted to say that, in deciding not to feed, we are simply withdrawing treatment and letting these patients die. Yet, these patients are not clearly dying. And, despite the sloppy way we sometimes talk about these matters, you cannot “let die” a person who is not dying. It is hard, therefore, to make the case for treatment withdrawal in these cases on the ground of uselessness. We may use those words, but it is more likely that our target is a (supposed) useless life and not a useless treatment. And if that is our aim, we had better rethink it promptly.

Is the treatment excessively burdensome? Alas, if these patients could experience the feeding as a burden, they would not be diagnosed as being in a persistent vegetative state. We may wonder, of course, whether having such a life is itself a burden, but, again, if that is our reasoning, it will be clear that we take aim not at a burdensome treatment but at a (presumed) burdensome life. And, once more, if that is our aim, we had better rethink it promptly.

Hence, although these are troubling cases, I don't yet see good or sufficient arguments to make the case for withdrawing feeding tubes from patients in a persistent vegetative state. I have not suggested that we have an obligation always and at any cost to preserve life. I don't see a clear precedent in the Judeo-Christian tradition for focusing on the preservation of life for life's sake in this radical way. I have simply avoided all comparative judgments of the worth of human lives and have turned aside from any decisions which, when analyzed carefully, look as if they take aim not at a dispensable treatment but at a life.