The ends of medicine at the end of life: understanding the ordinary-extraordinary means distinction in an age of pervasive technology

An enduring issue in Christian bioethics is locating respect for human life between two extremes: an absolute valuation and a valuation entirely conditional on life's quality.This issue finds expression in the use of the ordinary-extraordinary means distinction (OEMD), a burden-benefit calculus employed by Catholic and Protestant ethicists to judge the appropriateness of available life preserving means in particular cases.With the increasing accessibility of new technologies and procedures for extending life, unique threats to the usefulness of the OEMD are posed.In particular, humans have the novel capacity to stabilize and sustain life indefinitely in grave and unprecedented conditions.Disagreements result within and between Christian communities over how far the possibilities for preserving life should be taken.The advent of the persistent vegetative state (PVS) has caused such a disagreement.In examining the practical problem and its particular manifestation in the PVS, it is argued that reasonable measures for preserving human life are properly determined first of all in light of what is beneficial for the human being.Establishing what constitutes human benefit in the medical arena requires a philosophy of medicine reliant upon a substantive concept of the human being.A theological anthropology foundational for the OEMD and the ends of medicine is uncovered, underscoring the tension between given human ontological value and the possible realization of human ends without digressing into dualism.This anthropology also attends to the undue influence of technology in the present day.Protecting the efficacy of the OEMD and remaining consistent with its underlying anthropology require that new technological means of preserving life not be assumed to provide benefit prior to a moral examination of such means undertaken in the practical context.Moral obligation must not be allowed to expand in direct proportion to growing technological capacities to preserve life.Rather, medicine is best understood as a species of care.As a specialized type of care, it remains subject to the ends of nonspecialized care.A proper application of the OEMD today reveals that medical means are not the only (or even always the most appropriate) way to care for the perishing human body.v Résumé Situer le respect de la vie humaine entre deux pôles extrêmes -une valeur absolue et une valeur entièrement subordonnée à la qualité de vie -est une problématique persistante en bioéthique chrétienne.Elle est exprimée, notamment, par l'utilisation dans le milieu des éthiciens catholiques et protestants d'une grille pour distinguer les moyens ordinaires des moyens extraordinaires de maintenir une personne en vie dans des situations particulières, basée sur un calcul fardeau-avantages.Suivant l'accessibilité croissante de nouvelles technologies et procédures, cette grille de distinction entre moyens ordinaires et extraordinaires (DMOE) et son utilité font face à des menaces uniques.Notamment, les humains ont dorénavant la capacité de stabiliser et de maintenir la vie dans des conditions graves et jamais vues auparavant.Ce phénomène donne naissance à des divergences au sein des communautés chrétiennes : jusqu'où doit-on étendre la possibilité de maintenir un humain en vie?Et l'avènement de l'état végétatif chronique (ÉVC) a provoqué divergences.Dans l'examen de ce problème pratique et de sa manifestation particulière, l'état végétatif chronique, l'auteure fait valoir que les mesures raisonnables de maintien de la vie humaine doivent d'abord être déterminées à la lumière de ce qui est bénéfique pour l'être humain.Pour établir ce qui constitue un bienfait pour l'être humain dans la sphère médicale, il faut une philosophie de la médecine reposant sur un concept fondamental de ce qu'est l'être humain.Un fondement anthropothéologique sur lequel appuyer la grille DMOE et la finalité de la médecine est élaboré, mettant en relief la tension entre une valeur humaine ontologique donnée et la réalisation possible de la finalité humaine, et ce, sans digresser vers le dualisme.Ce fondement anthropologique rend également compte de l'influence indue de la technologique de nos jours.Pour protéger l'efficacité de la grille DMOE et rester fidèle à son anthropologie sous-jacente, on ne doit pas supposer que les nouveaux moyens technologiques de maintien en vie engendrent nécessairement des avantages.Il faut d'abord procéder à l'examen moral de ces moyens mis en œuvre dans une situation pratique.L'obligation morale ne doit pas s'étendre de façon directement proportionnelle à l'accroissement des capacités de maintenir un humain en vie.Plutôt, la médecine est mieux comprise comme une espèce de soins.En tant que catégorie spécialisée de soins, vi elle demeure assujettie à des buts non spécialisés de soins.Une application adéquate de la grille DMOE aujourd'hui révèle que les moyens médicaux ne sont pas la seule façon (ni toujours la façon la plus appropriée) de prendre soin d'un corps humain dépérissant.We are all creatures of time and place, and...the bioethical concerns of the present and future require seeing man's permanent problems in light of changing technological and social conditions, and in light of those philosophical orthodoxies that reign supreme in both our bioethics institutions and the culture as a whole.Yet the deepest problems of the age are always connected to the deepest problems of every age.... Eric Cohen, "In Whose Image Shall We Die?" New Atlantis 15 (Winter 2007), 38."inner life." 3 However, unlike in coma, cardiorespiratory function along with hypothalamic and brainstem autonomic functions, such as a "sleep-wake cycle," breathing, blinking, and reflexive responses, are completely or partially preserved.When not the result of a degenerative condition or developmental malformation the vegetative state can allow for internal regulation over the long term.Required for survival is artificial nutrition and hydration (ANH).4 Despite the fact that the swallowing reflex can remain intact, vegetative patients are unable to coordinate chewing with swallowing.Although other kinds of dignity and nursing care are offered to such patients, ANH is primarily responsible for stabilizing and maintaining this condition.Without them the patient would not survive long enough to progress from coma to persistent vegetation.A patient is diagnosed as persistently vegetative if the vegetative state neither proves to be a transient stage of recovery nor leads to the patient's death.Persistent vegetative state (PVS), the label given to the condition after several weeks, signifies the chronic nature of the state but does not indicate prognosis.Patients are only considered permanently or irreversibly vegetative after a period of some months, the precise time of which depends largely on causation.5 For example, if the cause is traumatic injury, at three months the chances that adult patients will recover with severe disability are 19 out of 100.They also have a 16% chance of recovery with no to moderate disability.At six months these probabilities reduce to 12% and 4%, respectively, and at twelve months the probability for any kind of recovery is less than 1%.In the case of an adult having experienced a nontraumatic injury, the statistics are graver still.If, at three months, the patient has not expired or emerged from the vegetative state, the probability of recovery with severe disability is approximately 6%, and the probability of good to moderate recovery is estimated at 1%.After this point, the probability of recovery with or without 3 Multi-Society Task Force on PVS, "Medical Aspects of the Persistent Vegetative State," part 1, New England Journal of Medicine 330, no.21 (1994): 1499-1508, http://content.nejm.org/cgi/content/full

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