The Expression of Life Quality - Essay Example

Quality of life Since the 16th century Roman Catholics have reflected on the extent of one's obligation to preserve life. These reflections were partly influenced by developments in medicine during the Renaissance. While it was clear that a Christian was not obligated to do everything to preserve life, it was unclear to what extent one was obligated to preserve life. Decisions about pursuing life-prolonging treatments were set within certain boundaries. On the one hand, one could not intentionally take innocent human life, including one's own; but, on the other hand, one need not maintain life at all costs. To do everything to maintain life at all costs could be nothing short of idolatry as Pius XII stated in 1958; it is to put human life before all else including God. Most medical decisions, however, fall somewhere in between these boundaries. Reflections on these decisions were articulated in the language of ordinary and extraordinary means. The expression "quality of life" has been used by the proponents of practices such as abortion, assisted suicide, and euthanasia; indeed "quality of life" has become a rallying slogan for those who favor such practices. There is an understandable tendency in some of these Episcopal statements to avoid any public formulation that might suggest endorsement of that kind of quality - of - life ethic. In the public context, these bishops tend to speak in language that portrays life as an absolute good and to eschew language about the quality of life. Such statements sometimes convey the impression that the distinction between ordinary and extraordinary means can be worked out in fairly objective terms (e.g. benefits of treatment, the proximity of a patient to death). In fact the language of benefit vs. burden ratio or proportionate vs. disproportionate treatment lends itself to images of a mathematical measurement. But this does not retain all the nuances of traditional teaching. While there are objective elements, such as whether or not a treatment is available or will be physiologically useful, the history of the distinction between ordinary and extraordinary means makes it clear that its deployment turns on the prudent judgment of the patient with the help of family and physician. The patient is the one who weighs risks, burdens, and benefits in light of a treatment's probable impact. The distinction depends upon the patient's quality - of - life judgments. The Pennsylvania bishops' statement on nutrition and hydration illustrates the tendency both to objectify the judgment about ordinary and extraordinary means and to misrepresent traditional teaching. For example, the bishops write that "the patient in the persistent vegetative state is not imminently terminal (provided that there is no other pathology present). The feeding--regardless of whether it be considered as treatment or as care--is serving a life -sustaining purpose. Therefore, it remains an ordinary means of sustaining life and should be continued." The bishops of the Maryland Catholic Conference also wrote that "[a] medical treatment should not be deemed useless, however, because it fails to achieve some goal beyond what should be expected." For them, medically assisted feeding and hydration is useful as long as the patient is capable of absorbing the nutrients delivered by the treatment. These kinds of statements reflect an erosion of the distinction between ordinary and extraordinary means. There are a number of ways in which the traditional teaching is being lost. First, it should be noted that the distinction between ordinary and extraordinary means traditionally has not been limited only to those patients who were considered to be terminal. In creating such a restriction the bishops are being quite innovative in their interpretation of the distinction. Pope John Paul II seems to limit the distinction's application to those who are close to death; in Evangelium vitae he distinguishes euthanasia from withdrawing aggressive treatment and, in so doing, appears to limit the distinction between ordinary and extraordinary means to situations "when death is clearly imminent and inevitable." The distinction, however, has not traditionally been tied to closeness of death, but to a judgment about the treatment's benefits and burdens. Second, in writing about a treatment and the preservation of life in isolation from a person's life, these particular bishops give the impression of having an incomplete model of medicine. One reason for the success of modern medicine has been increased specialization and attendant technology. Such advances present a difficulty, however, in that often no one is looking after the whole patient. A wide range of literature in bioethics, the philosophy of medicine, and medical sociology has addressed the complaints of patients and the concerns of physicians about the failure to treat the whole patient Third, assessing benefit in health care necessitates an important subjective component. What counts as benefit for one person may not hold for another. Cancer patents with similar pathologies and prognoses make different choices about proposed therapies because they view their benefits and burdens differently. What may seem to hold benefit at one point in a patient's life may not do so at another point. Discussion in bioethics and health policy has been ongoing over the past decade about "futile treatment". Aside from what is physiological futility, the term "futile" is highly subjective; what may be futile for one patient or family may be good for others. WORKSHEET 1) Preliminary considerations a) Catholic moralists today appear hesitant to speak about "quality of life." A number of Catholic hierarchs and theologians tend to avoid that expression because of public-policy debates surrounding abortion and physician-assisted suicide. In fact the term has been deployed by many hostile to traditional Christianity's views on these moral issues. While it is understandable that in today's political and cultural climate, particularly in the U.S., one might wish to avoid the term, it is important that Roman Catholic bioethicists and moral theologians recognize that quality - of - life judgments have played a central role in the traditional distinction between ordinary and extraordinary means. If we fail to understand the importance of quality - of - life judgments, we run the risk of misunderstanding that distinction and the important moral commitments it implies--all in the interests of winning a political battle. b) Dissatisfaction is a result of big numbers of people's poverty, numerous diseases caused at a time when they could be prevented or treated before it emerged in case the quality of life would have been higher and let to do so. 2. Identifying the problem a) In his doctoral dissertation first published in 1958 that examined the obligation to conserve human life, Daniel A. Cronin, now Archbishop of Hartford, repeated the conviction that the human person lacks perfect dominion over his or her own life. Since life is a gift from God, each person has only an imperfect dominion over it [1] Dominion over one's own life differs from the dominion human beings have over the rest of the creation. Juan de Lugo, who played an important role in developing the distinction between ordinary and extraordinary means argued that there is a fundamental difference between the dominion men and women possess over things and the dominion over their own life. Now we prove that man is not the master of his life this way: although man can receive dominion over things which are extrinsic to himself or which are distinct from him, he cannot, however, receive dominion over himself, because from the very concept and definition, it is clear that a master is something relative, for example, a father or a teacher, and just as no one can be father or teacher of himself, so neither can he be master of himself, for to be master always denotes superiority with regard to the one over whom he is the master. Hence, God Himself cannot be master of Himself, even though He possesses Himself most perfectly. Therefore man cannot be master of himself, however, he can be master of his operations, and therefore, he can sell himself and thus, improperly speaking, we might say he gives mastery of himself to another but he really does not give over mastery of himself basically or radically, but only mastery over certain of his operations, . . . therefore a man can dispose only of his own operations of which he is master, not of himself, (or to say the same thing) not of his own life over which he is not master, nor can he be [2] What emerged in Roman Catholic traditional teaching was an understanding of human life in which there is considerable, though limited, freedom given to human beings. One such limitation is that we do not possess total disposition over our own life. We are obliged to conserve human life. This obligation forbids any person to take his or her own life [3]. More difficult dimension of the obligation, however, is to determine the positive duty one has to conserve life. What is the nature and extent of one's duty to conserve life This question has particular importance in health care in determining the extent to which a person must seek treatment for disease or illness. In articulating one's obligation to seek treatment, traditional teaching sets out a distinction framed in terms of an understanding of one's earthly life and ultimate end. Life is understood as a gift in relationship to personal salvation and eternal happiness. So traditional teaching has argued for an obligation to conserve life that is balanced by other obligations and by the view that love of God orders all obligations. b) In recent years, advances in life -sustaining medical technology have led various groupings of bishops to revisit the distinction between ordinary and extraordinary means and apply it to contemporary medical-moral questions. They have been concerned particularly about artificial feeding and hydration of patients who are in a persistently vegetative state [4]. Several excellent statements by groups of bishops in various states have preserved the core of the traditional teaching and applied it to contemporary issues [5]. In some instances, however, bishops' statements have failed to preserve distinctions as formulated in traditional teaching. My comments here are restricted to that second group. I find this approach the best in reference to expressing the topic as it provides modern viewpoint to the problem. 3. Research a) The problem is quite broad and can be researched in terms of FICSIT Quality of Life Assessment, which is a scientific approach to the assessment of people's life quality. The first requirement for selecting measures to be included in the FICSIT common data base was a measure's established reliability and validity in research with old persons. The second requirement was its applicability to elders living in the community and in nursing homes. In the trials, interventions with elders living in the community are being tested at five sites. Interventions with those living in nursing homes are being tested at three sites. FICSIT presents special challenges because of the wide range of physical and cognitive functioning expected across the eight sites. Initial discussions showed it would be impossible for all measurements to be identical in both community and institutional populations. Since an estimated 80 percent of nursing home residents are cognitively impaired or have other mental health problems, investigators did not believe they would get valid responses to quality of life assessment instruments that require cognitive differentiation. Residence in a nursing home alters the range of possible responses in that nursing home residents are not expected to cook their own meals, to shop, or to participate in social visiting outside of the home. Because the primary focus of the trials is on frailty and injuries, it was important to go beyond activities of daily living measures and include a variety of measures of subjects' physical functioning. Standardized assessments of mobility, gait, balance, and strength were included in the common data base, with emphasis placed on observation-based measures to differentiate actual performance from self-reported capability. Subscales of the Sickness Impact Profile (SIP) that assess body care and movement, ambulation, and physical mobility were included. The number of chronic conditions and use of medication were measured for each subject. To reduce respondent fatigue, subsets of measures could be completed at separate data gathering sessions. Other domains of well-being or quality of life are important research interests in the trials. b) To obtain comprehensive, multidimensional assessments with minimal respondent burden, 17 questions comprising 5 subscales from the Medical Outcomes Study (MOS) Short-Form Health Survey were asked. The five subscales measure limited role functioning because of physical health, mental health, and social functioning. The subscales also measure bodily pain and general health perceptions. One question, "In general, would you say your health is excellent, very good, good, fair, or poor," was asked of all subjects. The predictability of this one item for mortality outcomes has been demonstrated in several studies. Because the remaining 16 questions are only appropriate for community-dwelling subjects, the MOS subscales are part of the common data base for community-dwelling subjects, but not for subjects at nursing home sites. The five subscales yield separate scores that can help to specify the interaction of respondent characteristics with particular quality of life dimensions, which is preferable to a single summary score that may mask the effects of health interventions on specific quality of life domains. 4. Producing ideas and solutions a) We can improve the quality of life by educing the poverty of people. It is not enough to say that all persons have equal moral claims on us; we need to ask how best to organize ourselves politically and economically to meet those claims. Which combinations of rules and institutions of governance are most effective What roles ought we to play as individuals in respect of the primary agents of aid and justice Analogies to ethical decisions by an individual in a hermetically sealed case actually obscure all these problems and questions. For while it is true that we often act as individuals, the causal relevance or impact of our actions depends on the positions we occupy within complex social systems. b) There are three main parts that make my point clear about reducing world poverty: 1. Analogies should be made between individual cases--actually, thought experiments--and more complex real-world situations and/or utilitarian positions about maximizing happiness and minimizing pain. These analogies and positions aim to reveal that there is no moral equivalence between our penchant for luxuries and the survival needs of poor people. 2. People should be imposed the idea that it makes no moral difference whether the person they help is a neighbor's child ten yards from them a Bengali whose name they will never know, ten thousand miles away. 3. People should sacrifice and a definite injunction to act: Donate a large portion of your income--(a) at least 10 percent, or (b) to really avoid wrongdoing, every cent not devoted to purchasing necessities. c) My solution to the problem is to advance health promotion efforts directed toward old people. People need to avoid stereotypes and myths about an issue. Among the myths are that health promotion means the prevention of disease rather than improving health status; that old people are unable to tolerate health promotion interventions, as for example, exercise regimens; that old people are not able or willing to change their health attitudes, behaviors, or lifestyles; that old people are difficult to recruit into studies and hard to evaluate; that behavioral or lifestyle changes in late life will have only minimal impact on the health and functioning of old people; and that intervention is not cost effective for the elderly. All the myths reflect issues that require evaluation in a clinical trial setting. d) Old people might face difficulties in changing their attitudes toward life even if it implies improving their its quality of. Read More