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Summary of ordinary and extraordinary Means of Preserving Life

The article titled “Ordinary and Extraordinary Means of the Preservation of Life: The Teaching
of Moral Tradition” written by Paulina Taboada has its major focus on the explanation of the
Church’s teaching in the field of medical ethics. It does this by exploring two aspects of the topic
viz; the historical development of the distinction between ordinary and extraordinary means of
preserving life and some inadequate interpretations of the Magisterium. The distinction between
the ‘ordinary’ and the ‘extraordinary’ means was first made by St. Thomas Aquinas although the
two terms were first implored by Domingo Banez in a debate on the moral nature of preserving
life. Two conditions characterize the Church’s teaching on the moral duty of preserving health and
life. First, the use of common medical treatments to safeguard life. Secondly, that such treatments
do not involve a physical or moral impossibility for the patient. When these two conditions are
met simultaneously, it is considered as ordinary means, thus morally obligatory but when one of
the conditions is missing, it is considered extraordinary and it is morally facultative for the
individual (relative norm).
Historical Development
The genesis of a ‘positive’ moral duty in preserving life can be traced back to the foundation of
Christianity. St. Basil has been found to praise medicine as a way of healing the sick while
condemning too much concern for the flesh. This had a profound influence on the moralists of the
16th century and their limits of the moral duty of life preservation. Moralists based their teaching
on the analysis of St. Thomas Aquinas’ concepts of positive and negative precepts. For Aquinas,
there is not just the ‘negative’ obligation of preserving one’s life by not committing suicide, there
is also a ‘positive’ or ‘affirmative’ obligation of taking care of one’s life by every possible means.
A more systematic development of medical sciences during the Renaissance led to the formal
application of these concepts as evident in the works of commentators of Aquinas like Francisco
de Vitoria and others. New discoveries in Medicine like surgical amputation challenged moralists
to look into what exactly constituted a moral obligation to preserve one’s life especially when these
new techniques were available without anesthetics and pain killers. Francisco de Vitoria’s work
stands out in distinguishing between the ‘ordinary’ and the ‘extraordinary’ means. He argues that
medicine and food are not the same, therefore, if one refuses to eat and dies from it, he incurs a
mortal sin but that is not true for someone who does not take medicine to prolong his life. Yet, he
adds that if a person is sure that a medication would make him recover and without it would die,
he would not be excused from mortal sin. These arguments led Vitoria to assume that a person
could be excused from a moral duty to prolong life when there is a condition of moral impossibility,
for instance, in a case of an unreasonable cost.
With the work of Francisco de Vitoria, the moralists of the tradition described the conditions that
make up the nature of the ‘ordinary means’ which include that the means has to be common, easy,
and not difficult as well as have the capacity to provide beneficial results according to one’s state
of life. On the other hand, the extraordinary means presupposes a physical and moral impossibility.
Among the elements of a moral impossibility are severity, excruciating pain, exorbitant cost and
exceedingly difficult means. This means that a means of preserving life is considered
‘extraordinary’ if it meets any of these four elements. An extraordinary means of preserving life is
simply optional and not compulsory. In determining the moral character of the ordinary and
extraordinary means, attention should be focused on both the individual sick person (relative norm)
and human beings in general (absolute norm). This is because what may seem ‘ordinary’ or
‘extraordinary’ to one individual may not be the same for another. The second reason is that
circumstances may differ even for the same person.
The Theological Foundations of the Traditional Teaching
The theological foundation of the traditional teaching is based on the virtue of justice. Cardinal
Juan argues that the dominion given to man doesn’t include his life in an equal respect. This means
that although man has been given a dominion over created things including his life, he is rather to
be an administrator than a person who exploits. Moving forward, it was in the 20th century that we
saw the inclusion of the traditional teaching in magisterial documents.
Pope Pius XII in 1957 made reference to the typical distinction between the ‘ordinary’ and the
‘extraordinary’ means in a speech delivered to a group of anesthesiologists. Also, in 1981, the
document of the Sacred Congregation for the Doctrine of Faith on euthanasia referred to the
ordinary and extraordinary means. The document explains that it is morally valid to be satisfied
with the ordinary means for preserving life that medicine can provide, and that it is also morally
valid to reject some treatments that prolong human life in a painful manner in the face of an
imminent death. Here, the document uses the terms ‘proportionate’ and ‘disproportionate’
therapies to characterize the distinction. Other documents of the magisterium that make reference
to this are the 1981 document of the Pontifical Counsel Cor Unum and the Pontifical Council for
the Pastoral Assistance of Health Care Workers published in 1995. Pope John Paul II’s Evangelium
Vitae (The Gospel of Life) confirms the traditional teaching by making a distinction between the
act of euthanasia and the so-called aggressive methods of medicine. The document argues that to
reject any disproportionate medical treatment because of the pain or burden it places either on the
patient and his or her family, is not an act of euthanasia, rather it is simply accepting the human
condition. The Catechism of the Catholic Church supports the idea of evaluating medical
treatments to determine if they are proportionate.
Misinterpretations of the Traditional Teaching
There exist some misunderstandings in the interpretation among health practitioners on the
distinction between ‘ordinary’ and ‘extraordinary’ means and what it implies. Health professionals
often equate the word ‘ordinary means’ to ‘common’, ‘usual’ and ‘extraordinary means’ as
‘uncommon’ or ‘unusual’. Although this interpretation has some understanding of the traditional
distinction, it does not fully capture the moral obligation such distinction holds for individual
patients. This is because morality is not simply based on what a higher number of people consider
right or wrong. Morality is more than just statistics.
Another misinterpretation of the distinction between the ordinary and extraordinary means is found
on the emphasis on the means rather than the persons who make use of those means. For instance,
medical professionals consider blood transfusion as an ‘ordinary’ means because it is common and
simple and regenerative therapy with stem cells as ‘extraordinary’ because of its complexity. This
interpretation is misleading since a hyperkalemia cancer patient in a terminal stage may not require
a blood transfusion because the cause of the disease cannot be corrected. Therefore, to equate the
moral with the common and simple seems inadequate. Rather than having an ideal list of therapies
that can be considered ‘ordinary’ or ‘extraordinary’, the moralists prefer to deal with the individual
situation of each patient.
Certain contemporary bioethicists like Paul Schotsmans and Ludger Hennefelder confuse the
proportionality and non-proportionality of the traditional teaching with the principles of ethical
proportionalism. In their view, the classic distinction between the ordinary and the extraordinary
can only operate within the framework of the ethical background called act deontology which they
do not subscribe. Also, the traditional teaching is ‘static’ and does not support the changing
dynamics of contemporary medicine. Schostmans tries to adopt the proportionalist theory which
makes the comparison between therapeutic means and ends. This means that the distinction
between what is called ‘ordinary’ or ‘extraordinary’ is determined by the end which is good health
in proportion to the means (adequate treatment, financial costs). From his viewpoint, it is
preferrable to distinguish between proportionate and disproportionate means rather than ordinary
vs extraordinary.
In his encyclical Veritatis Splendor (The Splendor of Truth), Pope John Paul II noted that although
this theory can have a widespread acceptance in the medical community, it is not rightly accepted
in the Church’s teaching because it justifies certain behaviors that are not in accordance with the
divine and natural law. In order to adequately interpret and apply the principle of therapeutic
proportionality, Sulmasy suggests that both the benefits and the responsibilities connected to a
therapy be weighed against the moral duty of preserving life. This means that to justify the
proportionality of a therapy, there should be no moral and pre-moral values placed before the good
of health and life itself, instead, it should be established that there is no grave inconvenience (moral
impossibility), so that the person adheres to the ‘positive’ duty of preserving his or her life with
the assumption that life is an indispensable good.
Nowadays, we find yet another widespread misinterpretation of the distinction between the
ordinary and the extraordinary means. This interpretation uses the ‘quality of life’ as its criteria for
permitting morally acceptable therapies. Proponents of this interpretation like Beauchamp and
Childress suggest that the words ‘ordinary and extraordinary’ should be replaced with ‘morally
obligatory’ and ‘optional’ treatments. The basic criterion in determining a morally obligatory
treatment is that the benefits outweigh the burdens. This means that it would be unnecessary to
treat someone when there is an assumption that the burdens will exceed the benefits, or the
treatment will be futile.
Furthermore, they argue that treatments which impose more burdens than benefits on patients does
not permit them to experience happiness and pleasure which is the intrinsic value of human life.
Hence, this view adopts the utilitarian position of maximizing happiness for the majority of the
people. It is very true that the concept of utilitarianism has a large adherence especially among
Anglo-Saxon Bioethicists. Certainly, this view deviates from the Traditional teaching because it
holds that the value of human life is happiness and pleasure. The widespread acceptance of ‘the
quality of life’ as the criterion for determining morally acceptable treatments in contemporary
medical literature shows the extent our societies have gone in undervaluing human life.
Final Analysis
The history of the distinction between the ordinary and extraordinary means can be traced back to
the works of the commentors of St. Thomas Aquinas in the 16th century. The traditional teaching
affirmed that a ‘positive’ moral duty exists to preserve one’s health and life with available medical
treatments when they promise hope for beneficial results and when using them does not cause
physical or moral burden on the patient. A treatment is considered ordinary when both conditions
are simultaneously met and extraordinary when one condition is missing. While the ordinary
means is morally obligated, the extraordinary means is morally facultative. The extraordinary
means is morally required when its use represents the mercy of God.
The traditional teaching has been confirmed in the documents of the Magisterium since the 20th
century with an emphasis that life must be respected from conception to natural death. Applying
the contents of the traditional teaching outside the context an ontological dignity of human life
may result to misinterpretations.
Taboada, P. (2008). Ordinary and Extraordinary Means of the Preservation of Life: The Teaching
of Moral Tradition. https://www.catholicculture.org/culture/library/view.cfm?recnum=8872