Modern Versions of the "Safer" Course

Anyone working a contemporary field of bioethics, such as environmental or agricultural biotechnology ethics but who also knows the traditional ethics taught in Catholic colleges in the past or with moral theology for counseling practical decision making  will see lots of "re-inventing the wheel." Contemporary applied ethics in biological topics have re-emphasized a moral principle of caution when the issue is a choice of  a "tool" (including policies or actions) where there is lack of certitude about the morally correct course of action. They call this the precautionary principle. It has various formulations but the gist of it is that when some tool (usually new)  is reasonably suspected to have a potential for harm, due not merely to ignorance of its unintended effects, but due to technically reasonable or plausible events involved in the use of the tool one needs to not act until some more secure knowledge, some removal of ignorance, can give us a better estimate of the likely risk. And the more serious and irreversible the risk, the more seriously one needs to be concerned with tentative  and incomplete scientific opinions of warning. One is not entitled to ignore these warnings simply because some other scientist has a sincere opinion to the contrary.

        Taking time out to check is what the principle calls for, and by the very nature of the case, those who wish to proceed without looking cannot point to absence of completely incontrovertible science about the two quantities involved in risk:   probability and seriousness of impact. This would use uncertainty about risk as a justification for abandoning caution, which turns the principle on its head.

                In traditional moral casuistry, the freedom which a person has to choose any  sincerely probable opinion on the rightness of an action or among the rightness of several choices of action (tool or policy)  is expressed as "ubi dubium libertas" (where there is doubt there is freedom) . Called "probablism" this generous  principle becomes restricted when injury to "third parties" [1][1] is involved. Then the opinion which protects the innocent third party best, or better is to be chosen.[2][2] In its current use as the "precautionary principle"  every case is  involves third parties and hence requires more restrictions on freedom to choose among opinions.

Extubation and the Safer Choice

        Applied to the Wendland case and others of that sort, if we suppose that suicide and homicide are what are not to be done, then the decision as to whether an act is suicide or not is much more freely decided when rival reasonable opinions exist than when someone else’s death (i.e. a possible homicide) is the issue. Thus if Robert Wendland were able to communicate his desires and asked for extubation, he might be able to say that death is not his intention, but that he rejects the tubes because they are neither curing him nor adding to his comfort and that his death is a result of the underlying illness and not suicide. But his surrogate decision maker is not Robert himself and his death would be the outcome of someone else choosing the extubation. Robert is a "third party."  The conservator may make a plausible claim that it is not homicide on the same grounds Robert used. But in the presence of also plausible evidence that the tubes and other interventions had actually restored him to a self-sustaining life, though diminished and handicapped, and that Robert is not even sick, let alone dying, from any underlying disease the surrogate must follow the safer course and is not free to choose extubation because of the lethal and certain harm to a "third person."

        There should be nothing too surprising about this. The underlying moral principle  is justice. Where third parties are involved, we are constrained by just concerns for others. One final comment: In California the use of a state constitutional right to privacy as a way to give patient autonomy the freedom to reject burdensome medical technologies is somewhat paradoxically applied here if "the safer  course", or precautionary approach is not used.  It is really the autonomy of the surrogate which is being given full range and the incompetent person's autonomy is being erased with his/her life.[3][3]


Catholic Institutional Ethics and the Safer Course

        The conjoined hospital and individual amici brief supporting Rose Wendland cites the Court's desire to keep Courts out of this kind of decision making.[4][4] So my question then is directed to the Catholic members of this brief submitting group: What sort of caring for the patient should they be supporting? Clearly they should be against killing or suicide by the  patient since that is not in the patient's best interest spiritually or physically. Even if there is evidence of a willingness in  conservatees to do something indistinguishable from suicide if they became grievously handicapped, if there is any evidence that they are willing to live now, they should not have that earlier will imposed on them by a Catholic agent. Where will that evidence come from in the non-comatose?[5][5] Clearly from their behavior.  Combative behavior is clearly not such evidence, unless it is clearly and consistently against the life-preserving equipment known to the patient as such. And this cannot be claimed while denying cognitive/volitional ability. 


        The  "accepted principles of bioethics" ( p. 31, A.C. Brief in Support of Rose Wendland in Supreme Court of Calif.) which the petitioners refer to is claimed to be supported by court precedents (Brophy and Thor) which state "The duty of the State to preserve life  must encompass a recognition of an individual's right to avoid circumstances in which the individual himself would feel that efforts to sustain life demean or degrade his humanity." It is my assertion that it is the duty of Catholic institutions to lead rather than follow bioethicists in formulating and interpreting principles. Hence in looking at the quotation which chooses preservation of life as a state interest, they should not forget the list of four state interests, especially when the list  supports the unquestioned Christian prohibition of suicide. "Preventing suicide" is one of those four interests. As an example of leadership, when the passage just quoted refers to "efforts to sustain life" should Catholic thinkers treat all efforts the same? Or should they suggest that when some effort is no longer a desperate effort to sustain a fading life, but a mere feeding via a tube of a severely handicapped  person who is not even sick, greater proof of the consistent will of the handicapped person to have that feeding ended would be appropriate? The request or support for the "safer" degree of proof is a request for the most difficult to obtain evidence that the patient would wish to die. Unlike many other kinds of medical interventions, the withdrawal of feeding from a patient who is otherwise not even sick will put that patient in the absolutely certain danger of death from a new cause and not from the underlying disease. And the fact that the removal  will be continued until death makes it difficult to deny that death, from a new cause, is its intention. And the Supreme Court stated that death is the intended purpose of the extubation.  As I have written elsewhere some extubations are legitimate exercises of the intention to "allow nature to take its course." But here the technical evidence is clear that nature is taking no course toward death at all and will not any time soon. It is only the extubation that will do that. Introducing intentionally a new cause of death is killing even in the case of a dying patient. The liceity of extubation, consistent with Catholic prohibition on suicide, in the case of the dying patient is argued on the grounds that the need for the tubal feeding is due to a dying process (the underlying disease or trauma) and hence extubation is not the introduction of a new cause of death. If this were not true, such removal would be to kill the dying patient and would be prohibited in Catholic teaching. This is a fortiori true when the patient is not dying at all.

        The A.C.  then goes on to argue that the conservator should follow statutory requirements "consistent with bioethical guidelines" (ibid.) to support "wishes" or "personal values" of the conservatee. The evidence is normally taken from prior words of the conservatee when the "safest" course would deal with the present will or intention of the patient. In saying that the decision by the conservator should be based "on what the  conservatee would want" the A.C. makes an implicit appeal to the past (ibid., p.32) In the case of a cognitively diminished patient, what he wants right now is important too. Catholic thinkers would feel no shame and actually rejoice at the tighter requirements of proof since the conservatee's earlier statements were almost certainly not confronted at the time they were made with an argument that some denials of "efforts to preserve life" would be tantamount to suicide. The hardly unlikely event that the patient now has a different opinion about "efforts to preserve life" and not commit suicide needs to be entertained in pursuing the safer course.  The confinement of evidence to the past narrows the conservatee's survival interests and enlarges the conservator's policy freedom. Since the latter enlargement could easily mean a killing or a substitute decision to commit suicide, this is not the direction Catholic thinking should favor. 

        It is true that both morally and legally Catholic institutions are obliged to allow patients to refuse medical interventions which can save their lives. These institutions do not have the moral responsibility for preventing all suicides, as long as it is clear that the hospital is not cooperating in them. But these institutions do have a moral responsibility to lend their weight to efforts to prevent killing, and to allow for evidence that an earlier de facto intent to choose suicide has been abandoned. In Robert Wendland's case  his efforts to secure his own comfort, to be free of annoyance, to enjoy social contacts can reasonably be seen as implying a desire to live. To ignore that implication is emphatically not to take the safest course.

        In this context the sifting of evidence for negative evaluations of Robert's  cognitive state by Rose Wendland and her presentations of an extremely bleak picture of his human activity before the media are not efforts to pursue the safest course. Catholic thinkers or speakers on this issue must face that such negative bias expands Rose's policy freedom and narrows Robert's survival chances. And that is the reverse of the principle of following the safest course.




[1][1] A third party, i.e. an outsider whose interests are not actively  represented or defended by advisor or advisee in a moral  deliberation, but who has justice demands on the outcome.

[2][2] Sometimes this is called the principle of "tutiorism"(from the latin for "safer"), but that term sometimes refers to a systematic preference for "safer" opinions. In the absence of third party interests, there is slim meaning to "safer" among really probable opinions since to know which was more probably true one would have to know where and what truth lay. In this context "safer" means less risk of harm to others.

[3][3] The California Supreme Court in the Conservatorship of Wendland, No. S087265, Aug 9, 2001, noted, somewhat ironically I believe, that a decision to kill Robert Wendland by starvation "would  represent the gravest possible affront to a conservatee's state constitutional right to privacy…"

[4][4] Amici Curiae Brief in Support of Rose Wendland and Robert Wendland

[5][5] In the comatose, another set of arguments is needed. For them, it is difficult not to say they are simply in a state of arrested dying.