Wednesday, November 25, 2009

Disgusting Theodicy, and Happy Thanksgiving

A reader has just called this bit of DOOM to my attention. The opening paragraph is enough to make any decent human being recoil in moral disgust....
The US Conference of Catholic Bishops released an “Ethical and Religious Directive” this month that would ban any Catholic hospital, nursing home or hospice program from removing feeding tubes or ending palliative procedures of any kind, even when the individual has an advance directive to guide their end-of-life care. The Bishops’ directive even notes that patient suffering is redemptive and brings the individual closer to Christ.
Happy Thanksgiving to the US readers. Hope you enjoy eating dead bird.

17 comments:

anonymouse said...

The argument that one ought not participate in the commission of a mortal sin is at least plausible. (I take it that this is the argument against following through on someone's wish to be taken off life support.) But is the church really suggesting that to inflict pain on the sinner brings the him closer to Christ and (so?) is a moral obligation?

Cool. I'm going to inflict some suffering today. No need to thank me. It's something I have to do.

Anonymous said...

See Tolstoy's "The Death of Ivan Ilych." Suffering brings to mind our mortality and brings us face to face with our ultimate destiny and dependence on God. Doping people to the point of incoherence robs people of the process of dealing with their mortality and ultimate destiny. This should not strike you so strangely, remember the proverbial "death-bed confession" and reconciling with folks we've had fall-outs with (and last rites). As Henry James once said, "The Catholic Church is the only Church to die in."

Anonymous said...

C'mon. If there's one thing decent human beings can disagree on, it's this issue.

Glaucon said...

@Anon9:41pm,

I take it that you think reasonable people can disagree over the redemptive value of human suffering -- that, after all, was the bolded passage in the original post -- not over whether it's permissible to ignore advance directives made by competent agents to guide their end-of-life care to impose a conception of the good they do not share. It's the latter that's so morally repugnant (to me, anyway)...

Platowe said...

Unlike many who will post about this issue, I tended to my father who died a horribly protracted, painful death from metastatic renal cancer, and who died at home because his WWII-era VA benefits wouldn't cover an extended stay in the hospital for his final weeks (this was many years ago--maybe the VA is different now). I dropped out of grad school meanwhile, and never took the one seminar that I first enrolled for in the first place. (No whining here--if I had to do this all over again, I would do the same thing. My dad wasn't a saint--but he and my mother needed me and that was that.) There was no redemption from those last horrible weeks. Few people today tend to their own dying parents in such situations, who do not recognize you, who moan from unyielding agony, whose stools ooze from bloody bowels that you must clean, whose obstructed trachea you clear pulmonary phlegm from, who despite lung failure you finally try your best and last to revive by CPR (and watch while the collapsed chest reveals a slowing, beating heart until at last still). There is no redemption, no honor, nothing at all of any merit to be found in such a death, except to tell you dear reader that you might be spared all this by the cultural trappings of our present medical system that will trade you the horror of having to experience all of this for the increasing expense of isolating you from this within the hospital setting. Nursing strangers will see and tend to all the bad--you and the insurers will just foot the bills--you will just have to be there at a heavily anesthetized, thus "peaceful" ending.

Redemption in suffering? I could use coarse language--but if you believe that, then you are beneath even my effort at such contempt, and I pity you your ignorant mythical self-delusion.

Anonymous said...

Platowe,

I'm very sorry to hear about the dept of suffering that you father (and you in a vicarious way) experienced.

It is true that one suffers in suffering, and it is an evil without a dought, but it nevertheless can be used redemptively. Certainly the Catholic Church does not advocate suffering for its own sake nor does it hold that it is good (contrary, I'm sure, to the thoughts of readers of this blog). It does offer us recourse within our inevitable suffering by allowing us to offer up our suffering with that of Christ on the cross for the good of ourselves and others. This doctrine giving us hope and brings good out of evil.

Certainly it is not a naive position of the Catholic Church to hold this, since no one in the history of western civilization has stared unflinchingly at the miseries of suffering than Catholics. St. Vincent DePaul, St. Peter Claver (who nursed slaves that came off the slave ships in South America), Theresa of Calcutta knew intimately the degrees of suffering, as well as its redemptive value.

"As for me, I long for love and light, but must it come so cruel and burn so bright." Leonard Cohen, Joan of Arc

anonymouse said...

Of course reasonable people can disagree on this issue. What is disgusting is offering the idea of redemptive suffering (about which reasonable people can disagree) as a reason for being OBLIGATED to force another person to suffer while, at the same time, determining the issue in policy.

I'm sorry for your and your father's ordeal, Platowe. My family went through something similar with my grandmother's multiple myeloma. The last weeks were agonizing, and everybody involved knew they would be agonizing. She was very explicit about what was to be done on her behalf and what was not to be done. The thought of her having to go to a hospital that would toss her wishes out, and then explain to me that it is good to suffer... There is no language coarse enough to respond to this.

Again, reasonable people can disagree about the morality of end of life decisions. Reasonable people can disagree about what Catholic hospitals should have the license to do. It is nowhere near the reasonable to offer up the goodness of suffering as a reason to accept an imposed obligation.

Platowe said...

Thank you both for your measured and reflective comments. Yes, I am still angry after almost three decades that my father suffered needlessly when good palliative care would have lessened the horror of his end. And I even concede that my own efforts at the end--my attempt at CPR--was irrational and senseless, and would serve no good purpose other than to try and comfort myself later with the thought that "I did all I could" (to what? Make him suffer a little longer?? But I was just a wet-behind-the-ears grad student then, and had never had the realities of death rubbed so much in my face.). But the overall lesson about suffering stuck. It serves no purpose; somehow or other it needs to stop.

I don't want to insult reflective religious commitment--but I cannot countenance so-called theology such as the Bishops' statement that endorses needless suffering.

Anonymous said...

I admit my thoughts about the matter stem more from an intuitional pull rather than evidence that is empirically substantive but I don't quite understand why some think it necessary to attach a reason--instrumental or otherwise--to suffering. Couldn't it simply be the case that suffering is wholly without reason?

You have my heartfelt sympathies, Platowe.

Anonymous said...

The quoted paragraph has two substantially different components.
Part I:
"The US Conference of Catholic Bishops released an “Ethical and Religious Directive... their end-of-life care."

Part II:
"The Bishops’ directive even notes that patient suffering is redemptive and brings the individual closer to Christ."

A couple of things here: This paragraph is the introductory paragraph of what reads to me to be a purposeful misrepresentation of what this document is about. Even if it were accurate, the relationship between part I (removing feeding tubes is bad, even if directed to do so by patient before hand) and part II (suffering is redemptive, somehow) is not causal. It is not the fact that Catholic teaching is that suffering can be, perhaps, more easily tolerated if seen as redemptive that causes the church's (or, better this particular national conference of bishop's) stance on feeding tubes. They are separate issues, delightfully placed next to each other in this article for us to infer all sorts of things that aren't in the document itself. The document (http://www.usccb.org/meetings/2009Fall/docs/ERDs_5th_ed_091118_FINAL.pdf), which isn't referenced in the article, does talk about not removing feeding tubes (unless it becomes 'excessively burdensome' and that is in the document, several times, contrary to what the article stated several times) and does talk about 'suffering' but they are never in the same context. Nothing whatsoever is deduced from how one might choose to deal with suffering (e.g., attempting to lighten the terrible burden of suffering by seeing some possible worth to it) to what is or is not morally permissible.

Moreover, from what I found, there's nothing in the document that specifies anything about overriding the pre-assigned choices of the patient. Instead the preference falls to "The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching" (paragraph 59). Of course the problem is in the last dependent clause of that quotation and would likely be cause for concern for many. But, at the least, if we are going to get agitated by what the document says, then we see what the document actually argues.

Regarding how to view suffering - this document says, "For the Christian ... suffering and death can take on a positive and distinctive meaning through the redemptive power of Jesus' suffering and death" (pg. 6). Note the 'can' - not 'must'. It is not that one must see suffering as redemptive, but the burden of suffering can be lightened, perhaps, a bit if one can through that suffering identify more closely with one's notion of God. There is no compulsion here - no demand - that suffering be seen as good. It is, I think, that suffering is terrible (as so well and painfully described by Plotowe) and, as suffering, there is sometimes no way out. One of the things Christianity should try to do is take suffering seriously (their God suffered for goodness' sake, which is almost if not entirely nuts), and encouraging people to take a measure of solace in their suffering is intended to ease that suffering, not embrace it.

Anonymous said...

Unless you think it is okay to kill someone to end his or her suffering, you've no basis to object to this. The rejection of the removal of feeding tubes is the rejection of using the withdrawal of nutrition as a way to bring about death. If there are other reasons that the feeding tubes are being removed (this is the 'extraordinarily burdensome' part), then the removal can be permissible.

As for the redemptive power of suffering, as was said above, there is no suggestion that the infliction of pain is justified by this. If anybody rejects the view that one can do evil that good may come, it is the Catholic Church.

?! said...

Anonymous 8:49 says:
"If anybody rejects the view that one can do evil that good may come, it is the Catholic Church."

I'm surprised this comment has remained unchallenged on this blog for more than two days. It could only be true if we ignore certain kinds of evil, and then only if we look at "official policy." Once we start looking at what the institution and its individual members do, it is implausible to think that the church actually rejects the view that one can do evil that good may come, even on its own definition of evil. And then once we get a normal definition of evil going, well, then...

Anonymous said...

It would be nice if a group of trained philosophers would consider the possibility that the original article quoted gets the Catholic church's view wrong, which it most certainly does. (Indeed, the author of the original article appears not to understand what the term "palliative care" even means.)

The new version of that particular ERD does not institute a blanket ban on removing life-sustaining treatment of any kind. The relevant ban is the long-standing one on intentional killing, and the new version of that ERD is an attempt to work out when removing artificial nutrition and hydration constitutes intentional killing. There is much disagreement about this among Catholics, even in the case of PVS.

The Catholic church does not hold the view that one must continue treatment at all costs, nor does it object to easing suffering by any means that do not constitute intentional killing. Catholic hospitals employ the same palliative care measures in use at any other hospital.

Of course one may take issue with the church's position that intentional killing is always wrong, or disagree with the basis on which it determines which actions count as intentional killings. But those are, of course, substantive philosophical disagreements.

anonymouse said...

Anon 11/27 2:53 makes good points. Let's look at the relevant language of the directives.

First the old one:

58.# There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient.

Here's the new directive

58. In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic and presumably irreversible conditions (e.g., the “persistent vegetative state”) who can reasonably be expected to live indefinitely if given such care. Medically assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be “excessively burdensome for the patient or [would] cause significant physical discomfort, for example resulting from complications in the use of the means employed.” For instance, as a patient draws close to inevitable death from an underlying progressive and fatal condition, certain measures to provide nutrition and hydration may become excessively burdensome and therefore not obligatory in light of their very limited ability to prolong life or provide comfort.

This is much more reasonable than the article, which seems to take the "or" that I bolded for an "and."

continued below because of excessive length...

anonymouse said...

The CHA's gloss on the points made by the revision is:

1. There is a general moral obligation to provide patients with food and water, including medically administered nutrition and hydration for those who cannot take food orally.

2. This general obligation extends to patients in a persistent vegetative state because of their fundamental human dignity. However, the Directive explains that this obligation ceases and the measures become "morally optional" when the measures cannot reasonably be expected to prolong the patient's life or when they become excessively burdensome. (This provision incorporates into the Directive the teaching of Pope John Paul II and the Congregation for the Doctrine of the Faith regarding medically assisted nutrition and hydration to persons in a persistent vegetative state. Catholic health care facilities have already addressed the implications of these statements).

3. The Directive also distinguishes between patients in a chronic state and those who are dying. This distinction has implications for the use of medically administered nutrition and hydration. For dying patients, medically administered nutrition and hydration may no longer be of benefit and may, in fact, impose significant burdens.


I guess the worry is an emphasis on 3. The obligation to sustain someone in a PVS is higher if the "significant burdens" clause is to apply to the dying and not to those in a PVS. But that doesn't really appear to be the case, from the language.

Finally, the CHA's interpretation in their Q&A on the revision of 58 loosens things up even more (pdf): http://www.chausa.org/NR/rdonlyres/D875E2BE-6DB8-4C2C-A868-63B06EA815F0/0/FINAL_QA_D58.pdf

Most relevant to the discussion here is this:

Will a Catholic hospital initiate MANH against the patient’s wishes?

No hospital or physician, including a Catholic hospital or physician, may ever initiate a nonemergency invasive procedure, such as inserting percutaneous endoscopic gastrostomy (PEG)tube, without the permission of the patient or his or her surrogate. This could be considered
an affront to human dignity and, in addition, could give rise to legal proceedings.


Inserting is different from removing, of course. But still, presenting an affront to autonomy as an affront to dignity here is interesting and more than I would have expected.

Even though this is a further specification of 58, it doesn't seem to be a narrowing in the way the article suggests--it clearly does not remove wiggle room. Apologies for not doing my homework before spouting off.

Finally, I still think talking about the redemptive suffering in a context of issuing directives with regard to the treatment of suffering is entirely inappropriate because it takes on the flavor of a reason (and is used in the interpretation of the meaning of the directive), even if it is benignly aimed at encouraging people to take a measure of solace and comfort in their suffering.

petrenkov said...

Rather cool place you've got here. Thanks the author for it. I like such themes and anything connected to them. I would like to read a bit more on that blog soon.

Truly yours
Alice Tudes

KTF said...

I don't particularly care for the sentiment expressed in the passage you put in bold, but you really ought to follow up on stuff someone sends you from the web before you post it. This particular little nugget of malicious information came from one David Dayen, who writes for the blog Firedoglake. I remember it well, because I saw it when it appeared, found it hard to believe, and did some fact-checking. I ended up writing the following comment on the post, which you will see on the site if you follow the link, under the name "oisin:"

This post is total bunk. Almost everything in it is false or grotesquely misleading, as I have been able to verify in about fifteen minutes of quick web-searching. What the Catholic Bishops passed last week is a slight revision of the wording of an old directive. The latest (Fourth) edition of the “Ethical and Religious Directives” has been in existence since 2001. This slight revision simply clarifies what has long been the Catholic Church’s position, especially as it applies to patients in a PVS.

The Catholic Hospital Association is not “disagreeing” with the Bishops or “responding” to the new revision in the passage the author quotes. And anyone who says the distinctions they make are not in the Bishops’ document is a fool. The CHA are themselves quoting *directly* from the Bishops’ document, you horse’s ass!! That can be verified here:

http://www.chausa.org/Pub/MainNav/News/CHW/Archive/2009/1201/Articles/w091201e.htm

The CHA’s position is that there is nothing really new here. They are right. They even say, a sentence or two after the passage quoted by Dayen, that the new revision simply “reflects existing Church teaching which Catholic health care facilities have already incorporated into their practice.” So absolutely nothing changes as a result of this new revision.

As to the substance of the issue, it is not a wild or crazy idea that it is immoral to withdraw life-*sustaining* measures such as food and water (as opposed to life-*saving* treatments such as medicines) from a patient in no danger of death. This includes patients in a PVS. Many other religious traditions hold the same view.

Do try to get at least SOME of your facts straight before you post, Dayen.