Ethics and Medics: A HISTORY OF EXTRAORDINARY MEANS, part 1

From Nancy Valko, RN:


September 2006 Volume 31, Number 9
A HISTORY OF EXTRAORDINARY MEANS
Scott M. Sullivan, M.A.


A knowledge of the past is necessary for an understanding of the present.
Given the critical importance of the distinction between ordinary and
extraordinary means for the moral analysis of any medical treatment, Ethics
& Medics begins a three-part historical survey on the development of this
principle-Ed.

The development of the Catholic moral perspective is a conservative action,
built upon a past system of standards, carefully developed and better
clarified over time. Moral principles begin in a primitive state, and are
later nourished and organically extended; that is, they are fashioned,
clarified, and expanded in response to new challenges arising in the public
square. In short, these moral principles develop from a historical base, and
it is this base that accounts for the principle's continuity. Far from
correcting, contradicting, or obscuring previous moral principles,
legitimate elaborations are additions that corroborate and preserve
antecedent truths. Any alleged development that disregards or contradicts
its base is not a true development but a corruption.

One contemporary Catholic bioethical principle is that a person is not
morally obligated to use extraordinary means to conserve life.1 But what are
extraordinary means, and how do they differ from ordinary means? Since "a
small error in the beginning is a great one in the end," it is crucial that
we look at the sources of this distinction in order to attain a clear grasp
of what its proper development and application should be today.2 This
two-part essay will cover the origin, development, and contemporary
magisterial understanding of the distinction between ordinary and
extraordinary means.


The Prohibition against Suicide
and the Duty to Conserve

The Catholic tradition holds that man is not the master of his own life.
Human life is a gift from God, who has dominion over life and death. Killing
per se is not against the moral law, but unjust killing ( i.e., killing the
innocent) is. Moreover, the commandment "Thou shall not kill" applies to the
killing not only of others, but also of oneself. Suicide is gravely evil for
at least three reasons: it violates the charity by which one should love
oneself, and it is a twofold violation of justice: it deprives the community
of one of its members, and usurps the authority of God.3 Man is a master of
himself only in the sense that he is allowed to dispose of the goods of
life, but the passage from this life to the next does not lie within his
licit purview.

Since man does not have absolute authority over his own life, it follows
that he is obligated to take proper care of it. Not only must he avoid
destroying his own life, he must also take positive steps to conserve it.
Without this positive element, the negative prohibition against suicide
would be meaningless. To not conserve one's life is to violate the same law
that prohibits a man from killing himself. If life is a valuable gift, then
those who have it should guard, protect, and care for it as they would any
precious thing. Thus, the duty to conserve one's life is correlative to the
illicitness of suicide. "Thou shall not kill" implies "thou shall conserve"
and so the prohibition against suicide and the duty of self-conservation are
two sides of the same moral coin.


Exceptions to the Duty
Yet there are cases that may be called "exceptions" to this principle.
First, there are those cases known as indirect suicide," legitimized by the
principle of double effect, where an action is chosen for a good cause, even
though a bad but unintended effect may result. For example, a soldier may
remain at his post even though he knows he will be killed, or a man may
licitly jump to his death from a tall burning building in order to avoid the
flames.4

I will not discuss exceptions of this sort. The topic here is a different
type of exception, where the means of conserving one's own life may be
omitted precisely because of the nature of those means. So the issue we are
pursuing is when, if ever, the obligation to conserve one's life ceases
because of intervening circumstances. The short answer is that the general
obligation to conserve never ceases, but one may be excused from fulfilling
the obligation in particular instances. Why? An excusing cause for
fulfilling the duty can simply be an inability to fulfill it. As you would
expect, a physical impossibility to conserve one's life excuses one from the
duty. Ought implies can. If someone is physically incapable of getting
water, naturally he is not morally bound to drink, and thus not guilty of
suicide if he dies of dehydration. However, there is another type of
exempting impossibility, a moral impossibility. This excuses one as well. A
moral impossibility is a fear, danger, or other circumstance that makes the
observance of the moral law extremely difficult. When this occurs, the duty
is said to be "morally impossible" to fulfill.
The Distinction between Positive and Negative Precepts
Moral impossibility excuses because the duty to do something good is in some
sense elusive. One cannot possibly be doing good deeds continuously, and
there are often times when we are not doing anything noticeably good at all.
As a matter of fact, with just a moment's reflection, it is apparent that we
can always not do bad things (we can always not commit murder, adultery, or
suicide), because these are not really actions, properly speaking, but
refrainments from action. Yet it is impossible to always be performing good
deeds. So while negative precepts (commandments that forbid action) bind
"for always and for all times" (semper et pro semper) even under danger of
death, positive precepts bind always in general but not in every single
instance (semper sed non pro semper).5 One is not obligated under every
circumstance to conduct a good action. Even though the basic obligation to
do good remains, the actuality of these actions binds only at a specific
time and under certain conditions.

Now, the duty to conserve life is a positive precept, and so it too "binds
always" but not for all time.6 Under certain conditions it does not oblige,
and the circumstance of moral impossibility is one of those times. Another
way of explaining it is that a moral impossibility is an extraordinary
difficulty, something that is not commonly experienced by people in general.
But no sooner do we make this distinction than we ask the question, What
constitutes a moral impossibility or extraordinary difficulty? When is a
fear, danger, or difficult circumstance enough to relieve one of the duty to
conserve one's own life? This brings us to our central concern, the
difference between ordinary and extraordinary means. Extraordinary means are
at least moral impossibilities, and ordinary means are not. A brief
historical survey of the most respected moralists in the Catholic tradition,
and an explanation of the magisterial teaching on this distinction, will
help shed light on how to discern the difference.


Historical Survey
The distinction between ordinary and extraordinary means begins, as we have
said, with the prohibition of suicide.7 Outside of this prohibition, the
early theologians do not say much; however, we begin to see the seed of its
development with St. Thomas Aquinas:

For a man is commanded to that which sustains his own body, for otherwise he
is a killer of himself . From this commandment therefore a man is held to
nourish his own body, and similarly we are bound to all things without which
the body is not able to live.8


If a man does not nourish his body he is "a killer of himself." To fail in
the positive precept to conserve is an omission tantamount to suicide.
Aquinas, however, knows that not all situations in which one may fail to act
are omissions. The sin of omission occurs only when there is a
non-fulfillment of a good that is due, that is, only when there is a
violation of justice.9 Yet Aquinas does not develop this notion of the duty
to conserve life except to recognize that it has reasonable limits.10 Later
theologians do.




Scott M. Sullivan, M.A.
The Center for Thomistic Studies
University of St. Thomas
Houston, Texas




Notes
1 See, for example, the U.S. Conference of Catholic Bishops, Ethical and
Religious Directives for Catholic Health Care Services, 4th edition
(Washington, DC: USCCB, 2001), nn. 56- 60.

2Thomas Aquinas, De Ente et Essentia, prooemium.

3 Aquinas, Summa theologiae II-II, Q. 64.5, trans. Fathers of the English
Dominican Province (New York: Benziger, 1947).

4 Alphonsus Liguori, Theologia moralis, lib. III, tractatus IV, cap. I, 367.

5 "Now sinful acts are evil in themselves, and cannot become good, no matter
how, or when, or where, they are done, because of their very nature they are
connected with an evil end, as stated in Ethic. ii, 6: wherefore negative
precepts bind always and for all times." Aquinas, Summa theologiae II-II, Q.
33.2.

6 "The sin of omission is contrary to an affirmative precept which binds
always, but not for always. Hence, by omitting to act, a man sins only for
the time at which the affirmative precept binds him to act." Ibid., I-II, Q.
71.5, reply 3.

7 I am greatly indebted, in this section especially, but overall as well, to
Fr. Daniel Cronin, The Moral Law in regard to the Ordinary and Extraordinary
Means of Conserving Life (Rome: Pontifical Gregorian University, 1958;
republished 1989); and Cronin et al., Conserving Human Life (Braintree, MA:
Pope John XXIII Medical-Moral Research and Educational Center, 1989).

8 Praecipitur autem homini quod corpus suum sustentet, alias enim est
homicida sui ipsius ... Ex praecepto ergo tenetur homo corpus suum nutrire,
et similiter ad omnia, sine quibus corpus non potest vivere, tenemur.
Aquinas, Super II Thes, cap. 3.

9Aquinas, Summa theologiae II-II, Q. 79.3.

10Ibid. II-II, Q. 126.1, reads, "Every man has it instilled in him by nature
to love his own life and whatever is directed thereto; and to do so in due
measure, that is, to love these things not as placing his end therein, but
as things to be used for the sake of his last end."