Opinion ID: 2276022
Heading Depth: 1
Heading Rank: 8

Heading: Characterizations of Medical Care

Text: The majority opinion seeks moral justification by citing outdated comments by Pope Pius XII (1939-1958) from an earlier time when the philosophy of death was not so prevalent. The recent pronouncements of Pope John Paul II built upon those of Pope Pius XII and are more in concert with traditional moral philosophy. Specifically, the majority opinion fails to make a common distinction in care. The best interest standard, as presented by the majority opinion, can easily be abused in the future because it does not differentiate between ordinary care and extraordinary care. By failing to safeguard basic care as mandatory, the standard would allow the withdrawal of these items under a quality of life determination. Although it cites some moral sources, it fails to properly conform the best interest standard to the limited type of care for which it is meant to be applied. Moral commentators tend to divide medical care into two categories: ordinary and extraordinary care. See, e.g., Rev. Michael P. Orsi, Catholic Thinking on End of Life Decisions (Pauline Books & Media 2000). Ordinary care is the proportionate means of preserving life. Ordinary care includes basic care, which is the provision of food and water, whether by artificial means or naturally, hygiene, and comfort. Extraordinary care includes surgical procedures and other types of care not generally associated with basic life support. Ordinary care may never be withdrawn from a living person. See, e.g. Orsi, supra. Extraordinary care is best suited to the standard adopted by the majority because it balances the many aspects of the decision, such as the proportionality of the care to the situation. A person needing extraordinary care may, when death is clearly imminent and inevitable, 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. Pope John Paul II, The Gospel of Life: Evangelium Vitae (1995), at para. 65, citing Congregation for the Doctrine of the Faith, Declaration on Euthanasia Iura et Bona (5 May 1980), at IV: AAS 72 (1980), at 551. However, and the crucial limitation in the cite is: so long as normal care due to the sick person is not interrupted. The distinction is clear, because of the limitation. Continuing, Evangelium Vitae states, To forego extraordinary or disproportionate means is not the equivalent of suicide or euthanasia; it rather expresses acceptance of the human condition in the face of death. Id. In other words, extraordinary care may be refused, but to refuse ordinary care is the equivalent of suicide or euthanasia. Therefore, the best interest standard contained in the majority should be limited to methods of extraordinary care. Safeguarding ordinary care as a basic right is the only standard consistent with the Kentucky law, as in DeGrella the powers of guardianship outlined above, or with the reading of the moral authorities cited by the majority. Ordinary care is basic health care. Clearly delineating the provision of ordinary care from extraordinary care, earlier this year, Pope John Paul II stated in a Vatican Address, I should like particularly to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act.  Address of Pope John Paul II, To the Participants in the International Congress on Life Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dillemas at para. 5 (March 20, 2004) (emphasis in original). Like all other persons, the sick person in a vegetative state, awaiting recovery or a natural end, still has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.), and to the prevention of complications related to the confinement in bed. Id. Concurrently, and with Pope John Paul II, an International Congress of health care providers and ethicists convened whose purpose was to discuss life-sustaining treatments and the vegetative state. See www.vegetativestate.org (last visited August 5, 2004). That congress resulted in a joint statement that accords with all points of the Pope John Paul II address. However, the strongest point is the accord with the distinction made above between extraordinary and ordinary care. The papal address states: The obligation to provide the normal care due to the sick in such cases (Congregation for the Doctrine of the Faith, lura et Bona, p. IV) includes, in fact, the use of nutrition and hydration (cf. Pontifical Council Cor Unum, Dans le Cadre, 2, 4, 4; Pontifical council for Pastoral Assistance to Health Care Workers, Charter of Health Care Workers, n. 120). The evaluation of probabilities, founded on waning hopes for recovery when the vegetative state is prolonged beyond a year, cannot ethically justify the cessation or interruption of minimal care for the patient, including nutrition and hydration. Death by starvation or dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission. Pope John Paul II Address, supra, at para 4 (emphasis in original). Finally, lest there be any confusion over the stance espoused on euthanasia, Evangelium Vitae, supra, at para 66, says, The choice of euthanasia becomes more serious when it takes the form of a murder committed by others on a person who has in no way requested it and who has never consented to it. The height of arbitrariness and injustice is reached when certain people, such as physicians or legislators, arrogate to themselves the power to decide who ought to live and who ought to die. Once again we find ourselves before the temptation of Eden: to become like God who `knows good and evil' (cf. Gen 3:5). By adopting a standard that allows one person to determine to kill another by omitting food and water from them, we are sanctioning murder. It is made worse through adopting the standard by citing references that clearly state that basic care may never be willingly and knowingly removed. Therefore, we ought not allow our standard to permit the State, through a guardian ad litem or otherwise, deprive a Kentuckian of life. The papal address also states that it is not enough to reaffirm the general principle according to which the value of a man's life cannot be made subordinate to any judgment of quality expressed by other men; it is necessary to promote the taking of positive actions as a stand against pressures to withdraw hydration and nutrition as a way to put an end to the lives of these patients. Id. (emphasis added.) The standard expressed in the majority opinion has failed to make an adequate distinction of ordinary care from extraordinary care. The reference by the majority opinion that the afterlife is somehow better than impaired life is founded only on sincere religious faith. These religions generally assert that euthanasia and suicide are wrong because the end of life is in God's hands, not man's. Not only does the majority ignore the above authorities, but also, it ignores the clear teaching of DeGrella against quality of life tests. Again, the quality of life ethic was rejected most recently in Grubbs v. Barbourville Family Health Center, P.S.C. : The argument that there is a kind of quality of life ethic is without any merit. This Court has rejected the quality of life philosophy in DeGrella By and Through Parrent v. Elston, Ky., 858 S.W.2d 698 (1993), which recognized that an individual has an inalienable right to life as declared by the United States Declaration of Independence and protected by Section One of the Kentucky Constitution. Any quality of life ethic favors the life of the healthy over the infirm, the able-bodied over the disabled and the intelligent over the mentally challenged. If logically extended, it could produce a culture that condones the extermination of the weak by the strong or the more powerful. The Nazi regime under Adolph Hitler is a not too distant reminder of this kind of eugenic approach. Unfortunately, such thoughts are not limited to foreign nations but can also be found in the writings of Justice Oliver Wendell Holmes in Buck v. Bell, 274 U.S. 200, 47 S.Ct. 584, 71 L.Ed. 1000 (1927), which approved of sterilization of the mentally incompetent. Taylor [v. Kurapati, 236 Mich.App. 315, 600 N.W.2d 670 (1999)], calls to our attention the influence that Hitler's experiments with sterilization had on the American eugenics movement. Eugenics espouses the reproduction of the fit over the unfit and discourages the birth of the unfit. Bowman, The Road to Eugenics, 3 U. Chic. L. Sch. Roundtable 491 (1996). 120 S.W.3d at 692 (Wintersheimer concurring). In conclusion, the majority standard has been built by ignoring the distinctions well seated within the authorities it used. Ordinary care, even for persons reliant on the State for such care, may not be subjected to a substituted judgment standard because it is the person's basic and fundamental right to receive such care. For these purposes, it fails to protect the basic rights of Kentuckians who rely on the State during these times when they are sick. Instead, the majority has opened the potential for atrocities similar to Bosnia where people relying on the State to speak on their behalf will be slowly killed by the removal of food and water. We have done so with the veneer of moral authority, but the core decision is full of error.