DIFFICULT MORAL QUESTIONS

Question 73: May a hospital serve a patient who refuses food in order to die?

I am chief administrator of a Catholic hospital. We have a patient, Miss Thornton, aged forty-three, whose condition currently is deteriorating. Thornton has refused to give her consent to medically indicated treatment and has said she no longer wants to go on living. For the past two days, she has been refusing to eat. However, she wants not only the nursing care that would be appropriate in any case, but certain other things required by her peculiar project, in particular, medication to alleviate her hunger pangs. A patient always is free to refuse medical treatment, and we cannot impose anything on Thornton against her will without incurring legal liability. But caring for her within the limits she has set seems to me to be helping her commit suicide.

Our hospital ethicist points out, however, that people foolishly, and sometimes irresponsibly, refuse treatment for other reasons. For example, a man under forty with a large family was admitted a few months ago. Tests showed he needed heart surgery, but he had the notion he would get well without it and was afraid of it because his father had died some years ago while undergoing similar surgery. Neither reassurances about progress since then nor pastoral counseling could alleviate his anxiety, and warnings about the risk he was running failed to move him. His wife pleaded with him, but still he would not consent to the surgery. We considered the possibility that his anxiety manifested psychopathology, but concluded that he was competent and that we had to accept his refusal of treatment. Still, we did everything we could to save him until he died, and nobody thought we should have done otherwise in that case. Therefore, our ethicist argues, while doing what we can for Thornton, we may observe the limits she sets on her treatment even though we think her refusal of treatment is wrong.

I am not sure what to make of that argument. But if it is unsound and I am right in feeling we should not go along with Thornton, I still am not sure what we should do. Of course, our options may be limited by legal considerations, and I shall consult our lawyers. But my question is: What should we do if we can?

Analysis:

This question concerns material cooperation. Assuming the patient is refusing treatment and food in order to end her life, the questioner is correct in thinking the hospital would be cooperating with suicide if it continues to care for her as she wishes. While the cooperation would not be formal, material cooperation probably would be wrong in this case. In the case of the man cited by the hospital ethicist, the hospital in no way cooperated in doing anything morally unacceptable in itself; rather, it formally cooperated with the patient in attempting to survive despite his unreasonable, but not suicidal, refusal of surgery.

The reply could be along the following lines:

Whenever a patient expresses a seemingly suicidal intention or, with any motive, refuses treatment or food that physicians or hospital staff consider appropriate, they should make a suitable effort to communicate with the patient and generally also with available family members or others close to the patient. The main purposes should be to correct any factual mistakes or misunderstandings, attend to any unmet needs for pain relief or any other sort of support, discover the patient’s real intentions, and persuade him or her to rectify them if necessary. Of course, the possibility that the patient is depressed or otherwise mentally ill also must be considered and ruled out. You seem to have fulfilled these responsibilities in the case of the man whose excessive fear led him to refuse indicated heart surgery. You may also have done so in the case of Miss Thornton, but that is not clear.

Perhaps her statement that she does not want to go on living really manifests feelings of depression or some nonsuicidal, though ill-expressed and perhaps mistaken, volition. If so, you should deal with her much as you did with the man who refused heart surgery. If you are convinced that Thornton really has chosen to commit suicide, arrange for her to be counseled and urged to change her mind.

Treatment that health care providers consider medically indicated sometimes promises such small benefits and/or entails such great burdens to the patient that he or she can rightly refuse it. Dying persons sometimes lose their appetites and reasonably refuse to eat. So, even if Thornton really is intent on suicide and should be exhorted to repent of that wrongful intent, she also should be supported in any morally acceptable alternative, including choosing on legitimate grounds to refuse anything she can rightly refuse.

If you have met your responsibility to communicate with Thornton and are convinced that she remains intent upon killing herself, you are right that caring for her as she wishes would constitute cooperating with her wrongdoing. Some ethicists faithful to the Church’s teaching probably would assert that giving her medication that would alleviate hunger pangs, or providing her with other care not required if she were not killing herself, necessarily would involve intending to bring about her death. But that is not so. Of course, some hospitals and their personnel might provide such care precisely to help patients intent on suicide attain their end—for example, offering medication to relieve hunger pangs so that a patient starving himself or herself to death would not give in to the urge to eat. That would be sharing her will to end her life, which would be morally wrong in itself, though it might be subjectively blameless for some or all of those involved due to their lack of sufficient reflection. However, I assume your hospital and its personnel would give Thornton the care she desires, including medication that would ease her hunger pangs, for other, legitimate reasons—to make her comfortable, dispose her to accept counseling that might lead her to change her mind, avoid legal problems. Even though Thornton needs some elements of that care only because she is refusing food and appropriate treatment, acting on any of those reasons would be morally permissible in itself. In providing the care she desires, therefore, your hospital and its personnel, though facilitating her suicide, would intend only to mitigate some of the bad side effects of her method of killing herself.

Still, doing anything that facilitates a gravely evil act often is morally unacceptable. Sometimes that is so because it occasions wholehearted cooperation in the sin; but you hardly are likely to be tempted to intend anything, whether as an end or as a means, that would contribute to Thornton’s death, and you could explain to hospital personnel the legitimate reasons for giving her the care she desires while warning them against being moved by sympathy to do anything precisely to help her bring about her death. Sometimes doing what facilitates an evil act is morally excluded inasmuch as it is unfair to third parties; but Thornton’s death may not injure anyone else, and even if her suicide does wrong others, your reluctant and limited contribution to what she is doing may not be unfair to them. Sometimes, though, such involvement in an evil act is morally unacceptable for yet another reason. It impedes one’s witness to the moral truth about the wrongdoing and may even encourage other people to embrace that sort of wrong. Those bad consequences are likely to follow if you voluntarily continue to serve Thornton as she starves herself to death. Therefore, in my judgment, you must resist doing so.

This point can be clarified by comparing this case with that of the man who refused indicated heart surgery. He plainly did not intend to kill himself but unrealistically expected to get well. You intended to help him try to survive without thereby facilitating any wrongdoing, since, even though his refusing surgery was unreasonable, it was not suicidal; he intended only to avoid surgery he mistakenly regarded as too risky. But I am assuming that Thornton does intend to kill herself. Thus, continuing to serve the man in no way impeded clear witness to the sanctity of life and the wrongness of suicide, whereas continuing to serve Thornton, by helping her mitigate the bad side effects of her chosen method of killing herself, might well suggest that life of poor quality is valueless and suicide can be appropriate in such a case. Moreover, your effort to save the man’s life despite his refusal of surgery surely did not encourage anyone else to refuse appropriate surgery. But mitigating Thornton’s hunger pangs and other unpleasant side effects would enhance the appeal of her suicidal project to people tempted to end their lives and might well encourage them to follow her bad example. If, however, you strongly resist involving the hospital in her suicide and explain your stand in terms of the hospital’s commitment to the intrinsic goodness of every person’s life, regardless of his or her condition, you will bear clear witness and do what you can to deter others from committing suicide.

What, then, should you do? Begin by asking Thornton to leave the hospital. If she does not wish to leave, explain to her that the hospital’s purpose is to promote health and protect life, that she was admitted for services in accord with that purpose, and that her refusal to cooperate in receiving those services has eliminated her reason for being in the hospital and her right to stay. Now she is imposing on hospitality, and impeding the hospital from carrying on its proper work to benefit people who need and want what it offers. Point out, too, that her wish that the hospital help her kill herself is unfair. The hospital and its patients cooperate voluntarily. Just as the hospital cannot justly compel patients to accept services they consider inappropriate, so patients cannot justly expect the hospital to provide services it considers inappropriate.

If Thornton refuses to leave, warn her that the hospital will do everything it can to disassociate itself from her project. Of course, you must consult your lawyers about what you can do. But I suggest that, in consulting them, you investigate not only the hospital’s possible legal vulnerability but also the possibility of obtaining a court order requiring Thornton either to accept food and the treatment she needs or to leave the hospital.

Even if the court is unlikely to issue such an order, seeking it would afford an opportunity to publicize the hospital’s commitment to human life and witness to the wrongness of suicide. Similarly, if a court order compels the hospital to provide Thornton with palliative care, you certainly should publicize the fact that this involvement is not voluntary, thereby making the public aware that the hospital is acting under protest due to legal duress. That will mitigate damage to the credibility of the hospital’s commitment and witness.