Ordinary vs. Extraordinary Care: A Moral Dilemma


Classical moral philosophy has always distinguished various forms of treatment according to ordinary versus extraordinary means or proportionate versus disproportionate means.  Sound moral judgments may be made by examining the type of treatment to be used, the degree of complexity or risk, the cost and availability of the treatment, and by comparing these elements with the results that can be expected, taking into account the state of the sick person and his physical and moral resources.  Every patient is entitled to medical treatment, no mater if the treatment is regarded as extraordinary or ordinary. 

A patient may interrupt his treatment means where the results fall short of expectations.  The wishes of the patient (and of the family if the patient is incapacitated) must be considered in any withdrawal of treatment.  Hospitals and health care facilities may judge that the investments, instruments, and personnel are disproportionate to the predicted results; however, a patient may still request such treatment.  While the medical institutions may be pressured to make a value judgment on the patient's life as compared to the expense and predicted/expected outcome, the decision to continue or arrest treatment should rest with the patient. 

One cannot impose on another the obligation to have recourse to a technique that is already in use but which carries a risk or is burdensome.  Such a refusal is not morally the equivalent of suicide; on the contrary, such a refusal marks acceptance of the nature of the human condition or a desire to avoid the application of a medical procedure that is disproportionate to the expected results that are expected. 

When death is imminent in spite of the means used, one is allowed to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life.  However, in such cases, the normal care due the sick person should never be interrupted, i.e., food and water should always be provided to a sick person as should pain mediation and other basic comfort care.  Texas Right to Life holds that food and water are not forms of medical treatment but are basic necessities due any human suffering or healthy. 

Food and water are indeed ordinary means and hence morally obligatory.  That being said, there may be some instances in which a patient with an inoperative, obstructive gastrointestinal carcinoma could not logistically receive an artificial feeding tube.  Other patients may have reached the point where digestion or processing food (even liquid food) is too burdensome or taxing on the bodily organs.  Hydration in some form, however, should be employed.  While there is never an obligation to use an ethically extraordinary means of treatment, these treatment options are optional and should be discussed and requested. 

In cases where a treatment is ethically extraordinary and simultaneously futile and the patient and/or family demand such treatment, doctors and health care facilities are not legally or morally obligated to provide such treatment.  In rare cases–usually when a patient is within minutes to hours of his death, withholding food, even if contrary to the patient or family's wishes is permissible as long as the patient is still receiving hydration.  Withdrawal of food and water will result in death due to starvation/dehydration within 14 days.  Moral actions require that intention, means, and end be evaluated accordingly in each case; denying or withdrawing nutrition and hydration intentionally (unless a patient is within minutes to hours of his death) to speed a person to his death constitutes an act of euthanasia and is morally equivalent to murder. 

Dest: American Bioethics Advisory Commission


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