Administration of the Sacraments
Where the administration of sacraments to an unconscious man is concerned, the answer is drawn from the doctrine and practice of the Church which, for its part, follows the Lord’s will as its rule of action. Sacraments are meant, by virtue of divine institution, for men of this world who are in the course of their earthly life, and, except for baptism itself, presupposed prior baptism of the recipient. He who is not a man, who is not yet a man, or is no longer a man, cannot receive the sacraments. Furthermore, if someone expresses his refusal, the sacraments cannot be administered to him against his will. God compels no one to accept sacramental grace. When it is not known whether a person fulfills the necessary conditions for valid reception of the sacraments, an effort must be made to solve the doubt. If this effort fails, the sacrament will be conferred under at least a tacit condition (with the phrase “Si capax est,” “If you are capable,” — which is the broadest condition). Sacraments are instituted by Christ for men in order to save their souls. Therefore, in cases of extreme necessity, the Church tries extreme solutions in order to give man sacramental grace and assistance.
The Fact of Death
The question of the fact of death and that of verifying the fact itself (de facto) or its legal authenticity (de jure) have, because of their consequences, even in the field of morals and of religion, an even greater importance. What we have just said about the presupposed essential elements for the valid reception of a sacrament has shown this. But the importance of the question extends also to effects in matters of inheritance, marriage and matrimonial processes, benefices (vacancy of a benefice), and to many other questions of private and social life.
It remains for the doctor, and especially the anesthesiologist, to give a clear and precise definition of “death” and the “moment of death” of a patient who passes away in a state of unconsciousness. Here one can accept the usual concept of complete and final separation of the soul from the body; but in practice one must take into account the lack of precision of the terms “body” and “separation.” One can put aside the possibility of a person being buried alive, for removal of the artificial respiration apparatus must necessarily bring about stoppage of blood circulation and therefore death within a few minutes.
In case of insoluble doubt, one can resort to presumptions of law and of fact. In general, it will be necessary to presume that life remains, because there is involved here a fundamental right received from the Creator, and it is necessary to prove with certainty that it has been lost.
We shall now pass to the solution of the particular questions.
Answers to the Questions
A Doctor’s Rights and Duties
1. Does the anesthesiologist have the right, or is he bound, in all cases of deep unconsciousness, even in those that are considered to be completely hopeless in the opinion of the competent doctor, to use modern artificial respiration apparatus, even against the will of the family?
In ordinary cases one will grant that the anesthesiologist has the right to act in this manner, but he is not bound to do so, unless this becomes the only way of fulfilling another certain moral duty.
The rights and duties of the doctor are correlative to those of the patient. The doctor, in fact, has no separate or independent right where the patient is concerned. In general he can take action only if the patient explicitly or implicitly, directly or indirectly, gives him permission. The technique of resuscitation which concerns us here does not contain anything immoral in itself. Therefore the patient, if he were capable of making a personal decision, could lawfully use it and, consequently, give the doctor permission to use it. On the other hand, since these forms of treatment go beyond the ordinary means to which one is bound, it cannot be held that there is an obligation to use them nor, consequently, that one is bound to give the doctor permission to use them.
The rights and duties of the family depend in general upon the presumed will of the unconscious patient if he is of age and sui jurist. Where the proper and independent duty of the family is concerned, they are usually bound only to the use of ordinary means.
Consequently, if it appears that the attempt at resuscitation constitutes in reality such a burden for the family that one cannot in all conscience impose it upon them, they can lawfully insist that the doctor should discontinue these attempts, and the doctor can lawfully comply.There is not involved here a case of direct disposal of the life of the patient, nor of euthanasia in any way: this would never be licit. Even when it causes the arrest of circulation, the interruption of attempts at resuscitation is never more than an indirect cause of the cessation of life, and one must apply in this case the principle of double effect and of “voluntarium in cause.”
Extreme Unction
2. We have, therefore, already answered the second question in essence: “Can the doctor remove the artificial respiration apparatus before the blood circulation has come to a complete stop? Can he do this, at least, when the patient has already received Extreme Unction? Is this Extreme Unction valid when it is administered at the moment when circulation ceases, or even after?”
We must give an affirmative answer to the first part of this question, as we have already explained. If Extreme Unction has not yet been administered, one must seek to prolong respiration until this has been done. But as far as concerns the validity of Extreme Unction at the moment when blood circulation stops completely or even after this moment, it is impossible to answer “yes” or “no.”
If, as in the opinion of doctors, this complete cessation of circulation means a sure separation of the soul from the body, even if particular organs go on functioning, Extreme Unction would certainly not be valid, for the recipient would certainly not be a man anymore. And this is an indispensable condition for the reception of the sacraments.
If, on the other hand, doctors are of the opinion that the separation of the soul from the body is doubtful, and that this doubt cannot be solved, the validity of Extreme Unction is also doubtful. But, applying her usual rules: “The sacraments are for men” and “In case of extreme measures” the Church allows the sacrament to be administered conditionally in respect to the sacramental sign.
When Is One “Dead”?
3. “When the blood circulation and the life of a patient who is deeply unconscious because of a central paralysis are maintained only through artificial respiration, and no improvement is noted after a few days, at what time does the Catholic Church consider the patient ‘dead’ or when must he be declared dead according to natural law (questions de facto and de jure)?”
(Has death already occurred after grave trauma of the brain, which has provoked deep unconsciousness and central breathing paralysis, the fatal consequences of which have nevertheless been retarded by artificial respiration? Or does it occur, according to the present opinion of doctors, only when there is complete arrest of circulation despite prolonged artificial respiration?)
Where the verification of the fact in particular cases in concerned, the answer cannot be deduced from any religious and moral principle and, under this aspect, does not fall within the competence of the Church. Until an answer can be given, the question must remain open. But considerations of a general nature allow us to believe that human life continues for as long as its vital functions — distinguished from the simple life of organs — manifest themselves spontaneously or even with the help of artificial processes. A great number of these cases are the object of insoluble doubt, and must be dealt with according to the presumptions of law and of fact of which we have spoken.
May these explanations guide you and enlightened you when you must solve delicate questions arising in the practice of your profession. As a token of divine favors which We call upon you and all those who are dear to you, We heartily grant you Our Apostolic Blessing.
