Dignity Denied?

By Ken Burrows

What does it mean to respect the inherent dignity of a person? In particular, what does it mean in the uniquely personal context of end-of-life health care decisions? Is a grant of full autonomy a prerequisite for respecting patient dignity?

This is no small matter because Catholic doctrines and policies govern end-of-life care decisions for the 15% of U.S. patients admitted to Catholic-affiliated hospitals each year as well as for individuals entering any of the 1,400 long-term care and assisted living facilities run under Catholic auspices. Unfortunately, those Catholic doctrines put individual autonomy in great peril.

The document titled “Ethical and Religious Directives for Catholic Health Care Services,” issued by the U.S. Conference of Catholic Bishops (USCCB), defines the relevant rules and policies. Although it states that “the inherent dignity of the human person” and “the free and informed judgements” made by patients concerning use of life-sustaining procedures should always be respected, it also states, “A Catholic health care institution will . . .  not honor an advance directive that is contrary to Catholic teaching.”

That’s conflicted at best and almost certainly means the promised respect for dignity and autonomy will be subordinated to Catholic teaching. Consider, for instance, that advance end-of-life instructions, DNR (do not resuscitate) orders, and directives in living wills can all be dismissed by a Catholic institution if their stipulations are contrary to church teaching, even if the patient is not a Catholic. It is difficult to imagine a point in one’s life when autonomy is more precious and where it can be so arbitrarily annulled. This does not respect dignity.

There is, additionally, a freedom of conscience issue at stake. Patients caught up in conflicts between Catholic dogma and their own conscientiously chosen health care decisions can find themselves bound by religious tenets they do not personally accept and be made to suffer for it. Depending on their health circumstances and availability of alternate resources, they may be powerless to do anything about it. This does not respect dignity.

If the denial of autonomy results in prolonged trauma or humiliation for the patient, the Directives say such patients “should be helped to appreciate the Christian understanding of redemptive suffering.” Never mind that it is suffering itself these patients have made conscientious choices to avoid in the first place and never mind that if these patients are themselves not Christian, such a solution adds the burden of unwanted proselytizing. This does not respect dignity.

Are the bishops themselves conflicted in their thinking on these rules? Their Directives at one point concede that a person can forgo extraordinary means of preserving life if those interventions, “in the patient’s judgement” [italics added], entail an “excessive burden.” Even medically assisted nutrition and hydration are deemed optional when they would cause “significant physical discomfort.” And yet at another point the Directives insist the same medically assisted nutrition and hydration are morally obligatory for patients who cannot take food or water orally, and the obligation “extends to patients . . . who can reasonably be expected to live indefinitely if given such care.” Here the exceptions based on “excessive burden” or “significant physical discomfort” for the patient are not mentioned.  

This much seems clear: A guarantee of autonomy at the end of one’s life should not be this confused or equivocal. Respect for dignity that is this malleable is dignity denied.