“How Virtues Become Vices,” in EngelhardtH.T.Jr., and SpickerS.F. (eds.), Explanation and Evaluation in the Biomedical Sciences (Dordrecht: D. Reidel, 1975), p. 105.
2.
Such would be the case for the sort of patient who would have recovered without access to an ICU, as well as the sort of patient who would not survive despite access to an ICU. Whether these sorts of patients can be reliably identified, and the relevance of this identification to what is here called the temptation of technology, is treated in part III of this paper. The sort of patient who does give evidence of benefitting from ICU admission is the unstable, moderately ill patient. CharlsonM.E., and SaxF.L., “The Therapeutic Efficacy of Critical Care Units from Two Perspectives.”Journal of Chronic Diseases, 40 (1987), pp. 31–37.
3.
22.5% of increase of health care costs for 1973-1983 are due to expansion of service according to the September, 1985 data and of the Division of National Cost Estimates, Health Care Financing Adminstration. AndersonG.F.“Data Watch: National Medical Care Spending,”Health Affairs.4: 3 (Fall 1985), p. 102.
4.
E.g., by KalbP.E., and MillerP.E. in “Utilization Strategies for Intensive Care Units”, Journal of the American Medical Association, 261 (April 28, 1989), p. 2389.
5.
VesaliusAndresDe humani corporis fabrica librorum Epitome (Basil: J. Operinus, 1543).
6.
The Antwerp Extra ordinisse Posttijdinghe of April 10, 1650, reported that “[t]hat in Sweden a fool had died who had claimed to be able to live as long as he wanted” (quotation from LindeboomG. A.Descartes and Medicine (Amsterdam: Rodopi. 1978), p. 94). Abbe Picot, who had lived with Descartes in Holland, wrote of him “that he would have sworn that it would have been impossible for Descartes to die at the age of fifty-four, as he did, and that, without foreign and violent cause as that which deranged his ‘machine’ in Sweden, he would have lived five hundred years” (AdamC., and TanneryP. (eds.), Oeuvres de Descartes (Paris: Leopold Cerf. 1897-1913), vol XI, p. 671. Surveying Descrates’ writings about how to maintain his health. Lindeboom infers that Descartes thought “the natural span of life to be more than a century” (op. cit., p. 96: cf, pp. 93-97).
7.
Cf. the Discalced Carmelites of Salamanca, the so-called Salmanticenses: “Also, in order to preserve one's life, he is not bound to use all possible remedies;, even extraordinary ones, excessively hard-to-obtain medicines, costly foods, going to a more healthful territory, so as to live longer” [Nee etiam tenetur aliuis ad conservandam vitam uti omnibus possibilibus remediis, etiam exiraordinariis nimirum exquisitis medicinis, cibis pretiosis, ire ad terras salubriores ad ampluis vivendum … (Cursus Theologia Moralis (Venice, 1734), Tom. Ill, Tract. XIII, de restitutione, cap. II, punct, 2, sect. 2, n. 26)] This tradition is preserved, e.g., in SabettiA., and BarrettA. T.Compendium Theologia Moralis, 33rd ed. (New York: Frederick Pustet Co., 1931), p. 269: “Is one bound to use extraordinary remedies to save life?. … No, and the reason is that the affirmative precept is not necessarily to be fulfilled in every manner possible but only by that which is accessible and common.” [An teneatur quis uti remediis exiraordinariis ad vitam servandam? … Neg. <atur>, et ratio est, quia praeceptum affirmativum non est necessario adimplendum omni modo possibili, sedeo tantum qui est obvius et communis.] Note that the analysis does not restrict the principle to saving one's own life; it would apply to any life which one is charged to save.
8.
… non tamen est tanti momenti hoc vitae bonum ut extraordinaria diligentia procuranda sit ejus conservatio: alius est earn non negligere et temere projicere, ad quid homo tenetur: aliud vero ist eam quaerere et fugientem ex se retinere mediis exquisitis, ad quid non tenetur, nec idea censetur moraliter mortem velle aut quaerere… (De Justitia et Jure (Paris: Vives, 1869), Disp, 10, Sect. 1, n. 29). Franciscus Vitoria(d. 1546) contrasts common foods with “very delicate” foods, e.g., “hens and chickens”, which one is not obligated to use, even if one had the resources, and the physicians said that such foods would prolong his life for 20 years, and he knew for certain that they were correct (Baltran de HerediaV. (ed.), Commentarios a la Secunda Secundae de Santo Tomas, (Salamanca: Biblioteca de teologos espanoles, 1932-1952), in II: II, a. 147, art. 1).
9.
CroninD. A.The Moral Law in Regard to the Ordinary and Extraordinary Means of Conserving Life (Rome: Typis Pontificae Universaitatis Gregorianiae, 1958), pp. 96–97, where he tabulates these as standard phrases among the 50 major writers from Vitoria to the time of his work.
10.
For example: “The absolute norm <sc: in contrast to the relative norm in gauging what is extraordinary in regard to cost> establishes a maximum amount beyond which no one need go in spending money to care for his health. This norm is based on that which people in general would find very costly. The average person would experience very grave inconvenience in paying for medical care which costs a great sum of money. It is difficult to fix the amount exactly, but it seems that in normal times $2,000 or more would certainly constitute such a ‘great sum’ for the average man. Hence if the treatment required for one's cure of a fatal disease would cost $2,000 or more, he would not be obliged to employ so costly a remedy. “Let us suppose that an individual whose health requires costly treatments is exceedingly wealthy. He could, without being caused any inconvenience by the expense, pay for such medical care. Despite his financial status, treatments costing $2,000 or more would be considered extraordinary means of preserving his life. … In his case the (absolute rather than the relative norm should be applied.” HealeyE. F.Medical Ethics (Chicago: Loyola University Press, 1956), p. 96. Another example: “No one, not even the very rich, is obligated to change his residence to another region, or to travel to distant baths, even if he cannot otherwise continue to live.” [Nemo, etiam ditissimus, obligatur ad sedem in alia regione ponendam, vel ad balnea longinqua mienuda, eliamsi aliler vilam prolrahere nequeat.] E. Genicot, Theulogia Moralis Institutiones, Vol. I, 4th ed. (Louvain: Polleus et Ceuterick. 1902), p. 346.
11.
Lest this sentence's last phase be construed as an unwarranted construal of spes salutis, cf. the Rev. R. McManus, who prepared the theological opinion sought of the Diocese of Providence, R.I., by the plaintiffs family, in a suit to have artificial nutrition and hydration removed from the comatose plaintiff: “[T]he medical treatments which are being provided the patient, even those which are supplying nutrition and hydration artificially, offer no reasonable hope of benefit to her, This lack of reasonable hope or benefit renders <them> … futile and thus extraordinary …” (Origins. 17: 2 (January 21. 1988), p. 547). The case was decided in the plaintiffs favor: Gray v. Romeo and the State of Rhode Island, United States District Court for the District of Rhode Island, Civil Action No. 87-0573B. October 17, 1988.
12.
Cf. FeinsteinA. R.“An Additional Basic Science for Clinical Medicine: IV, the Development of Clinimetrics.”Annals of Internal Medicine.99 (1983), pp. 843–848.
13.
For example, a “young woman has a rare cardiac ailment. There is a chance of curing her with an extremely delicate operation: but it is only a chance. Without the operation, she can hardly live a year. With the operation, she may die on the table or shortly afterwards: but she also has a chance, though considerably less than an even chance, of surviving and of being at least comparatively cured. This operation seems to be a clear example of an extraordinary means of preserving life, especially because of the risk and uncertainty that it involves.” KellyG.Medico-Moral Problems (St. Louis: The Catholic Hospital Association. 1958), p. 129.
14.
Noldin-Schmidt, considering the question whether there is an obligation to undergo a grave surgical operation or significant amputation, answers that “the more ancient authors commonly deny <sc.: such>, because an operation is an extraordinary means.<in al.> sometimes on account of the inconvenience of the loss of a limb. This certainly holds even today…” [Antiquiores auctores communiter negant, quia operatio… quandoque ob incommodum privationis membri est medium extraordinarium. Hoc certe etiam hodie valet…]NoldinH., and SchmittA.Summa Theologia Moralis, Vol. II, De Pracepetis, 25th ed. (Leipzig: Felix Rauch, 1938), p. 308.
15.
De Lugo observes that, “if someone condemned to burn, when he is already surrounded by the flames, were to have at hand water with which he could extinguish the fire and prolong his life, while at the same time other wood is being brought forward and burned, he would not be thereby bound to use this means to preserve his life for that brief a time, because the obligation of preserving life by ordinary means is not the obligation of using the means for that brief a prolongation, one which, <sc.: because it is too little, parum> is reckoned morally as tantamount nothing …[… si enim quis ad ignem damnatus, dum jam flamma circumdatus est haberet ad manum aquam, qua posset ignem extinguere et vitam prolrahere, quamdiu alia ligna afferuntur et acvenduntur: non ideo teneretur eo medio uti, ut vitam illo brevi tempore conservaret: quia obligatio conservandi vitam per media ordinaria, non est obligatio utendi mediis ad illam brevem conservationem quae <viz.: parum> moraliter pro nihilo reputatur] op. cit., n. 30.
16.
Pius, XII, Pope, “Le Dr Bruno Haid.” November 24, 1957, Acta Apostolicae Sedis, 49 (1957), p. 1030.
17.
I refer to his phrase “a grave burden for oneself or another” (my emphasis). Pope Pius XII thus expresses what is only implicit in Sabetti and Barret (see above, n. 7). The “oneself is the patient; the “other” probably refers to the family as helping to pay for the provision of care. He later remarks that insofar as the family has rights and duties apart from being the patient's proxy, “they are usually bound to the use of ordinary means” (op. cit., p. 1032). These remarks would now extend to the third-party payer.
18.
Op. cit. (n. 11), p. 138.
19.
Op. cit., p. 139.
20.
Op. cit., p. 135.
21.
This defect vitiates his otherwise excellent earlier articles “The Duty of Using Artificial Means of Preserving Life.”Theological Studies.11 (1950), pp. 203–230, and “The Duty to Preserve Life.” Theological Studies. 12(1951), pp. 550-556.
22.
Cf. AaronH. J., and SchwarzW. B.The Painful Prescription: Rationing Hospital Care (Washington: Brookings Institute. 1984).
23.
BerensonF. A.Intensive Care Units (ICUs): Clinical Outcomes, Costs, and Decisionmaking, Washington, D.C.: Congress of the United States Office of Technology Assessment, 1984, p. 36.
24.
KnausW. A.A Comparison of Intensive Care in the U.S.A. and France, Lancet.2 (18 September 1982), pp. 642–645.
25.
KnausW. A., ZimmermanJ. E., WagnerD. P.“APACHE — Acute Physiology and Chronic Health Evaluation: A Physiologically Based Classification System”. Critical Care Medicine.9 (1981), pp. 591–597; W. A. Knaus, E. A. Draper, D. P. Wagner, J. E. Zimmerman. “APACHE II: A Severity of Disease Classification System”, Critical Care Medicine 13 (1985). 818-829.
26.
For example. LemeshowS., TeresD., PastidesH., AvrunimH. S., SleinbrubJ. S.“A Method for Predicting Survival and Mortality of ICU Patients Using Objectively Derived Weights”. Critical Care Medicine.13 (1985), pp. 519–525. See also S. D. Horn, B. Chachich, C. Clopton. “Measuring Severity of Illness: A Reliability Study”. Meical Care, 21: 3 (July 1983) pp. 705-714.
27.
WagnerD. P., KnausW. A., DraperE. A., ZimmermanJ. E.“Identification of Low-Risk Monitor Patients Within a Medical-Surgical Intensive Care Unit.”Medical Care.21: 4 (April 1983), pp. 425–434.
28.
Msgr, O. Griese has recently argued in “Pope Pius XII and ‘Medical Treatments”, Linacre Quarterly. 54: 4 (November 1987), pp. 43-49) that nutrition and hydration and drugs count as minimal measures normally and customarily intended for the maintenance of life” (p. 48, quoting with approval a report of the Holy See's Council on Health Affairs), i.e., as ordinary rather than extraordinary means, even when the alimentation is artificial as in the case of the comatose. My point, of course, is not about artificial alimentation. However, to cite Fr, McManus again (op. cit. above, n. 11): “This lack of reasonable hope or benefit renders the artificially invasive medical treatments”, which in this case were artificial nutrition and hydration, “futile and thus extraordinary, disproportionate and unduly burdensome. Moreover, the continuation of such medical treatments is causing a significant and precarious economic burden to Mrs. Gray's family.” One must be careful not to ignore the question of whether the custom referred to by the Holy See's council has become corrupt when it accepts as usual treatment that which would usually constitute a significant burden upon family, health care professionals, health care facilities, and third-party payers. Cf. Kelly's remark: “I once asked the mother superior of a home for incurable cancer patients whether they used such things as intravenous feeding to prolong life. She replied that they did not. They gave all patients devoted nursing care: they tried to alleviate pain; and they helped the patients to make the best possible spiritual preparation for death. Many very good people with whom I have spoken about this matter think these sisters have the right idea ‘the good Christian attitude toward life and death” (op cit., p. 139). One could argue plausibly, pace Msgr, Griese, that Pope Pius XII's remarks cited above are in this spirit. For a recent study in this spirit, see WrayN.“Withholding Medical Treatment from the Severely Demented Patient,”Archives of Internal Medicine, 148 (September 1988), pp. 1980–1984.
29.
In 1978, average hospital costs for 498 ICU patients came to $9,491, compared with $1,361 for 118 non-ICU patients (ParnoJ. R., TeresD., LemeshowS., BrownR. B.“Hospital Charges and Long-Term Survival Versus Non-ICU Patients,”Critical Care Medicine.10 (1982), pp. 569–574).
30.
I have benefitted greatly from H. T. Engelhardt, Jr.'s substantive comments and criticisms of several drafts of this paper, I am also indebted to criticism by L. McCulloch and Becky Cox White of the penultimate draft.
