This should not be the case and for Catholics at least, there is a clear explanation on the Catechism on what euthanasia is and what it is not. Euthanasia is a deliberate killing either by an act of commission or by an act of omission – not giving treatment when it should have been treated.

We distinguish between ordinary treatment and extraordinary treatment. Usually people think of advanced life support or Cardiopulmonary resuscitation when thinking about extraordinary treatment, but in reality it has nothing to do with the state of the art of the treatment; it has to do with what the patient feels is ordinary or extraordinary for him or her. Doctors, as advised by Pope Pius XII in 1952, and as is upheld also in secular medicine should not give any form of treatment however without the patient’s consent. It is the patient himself who is morally obliged to take ordinary treatment and care. Not taking them would be a moral wrong but this does not imply that doctors can give treatment without consent. When patients cannot give consent, it is the next of kin whose wishes should be taken into consideration (always within what is permissible by law and moral theory).

Many would ask whether food and water are ordinary. The church has expressed its opinion to US catholic ethicists and doctors following the Terry Schiavo case. In principle, food and water should be considered ordinary. But again the principle of deciding what is ordinary and extraordinary lies on the conscience of the patient. This distinction of ordinary and extraordinary allows one, even if conscious, to refuse treatment which he considers burdensome and prevents one from refusing treatment to simply terminate his life because he has an illness. This would of course mean euthanasia.

Conversely one is not obliged to receive treatment deemed to be futile. Thus a person who has cancer and in admitted to hospital with a chest infection should morally accept the treatment unless he or she is actually in the final stages of life where treating the infection would be simply prolonging the agony. But if the infection can be treated and the patient sent home to live another couple of years or several months, then the distinction between ordinary and extraordinary cannot apply. Nevertheless the patient can still refuse treatment but it is on his or her conscience.

Thus there recently was a Programme which represented a real-life scenario. An elderly lady developed renal failure and had to be put on dialysis to be kept alive. On dialysis she could have lived another few years. Perhaps a transplant could have been offered in the future. Yet she said that she had lived a full life, was too old, and wished it to remain at that. She refused treatment – treatment which although can be considered extraordinary would have given a reasonable quality of life. Patients of course have a right to refuse treatment without giving any reason. In an emergency, doctors would still probably be obliged to treat unless these sort of directives in advance are given legal status.

Of course the film implied that the woman simply wanted to die, irrespective of making a decision on whether the treatment was disproportionate or unbearable. She simply wanted her life to enter. The film give us the impression of a deliberate act and therefore of a refusal of ‘ordinary’ treatment. But this is just a film. In a real-life scenario and ethicist or a chaplain would have to explain to her the moral obligations which her religion suggests. But religion can only be given to those who accept it willingly. And even here, we are not in a position to judge on what one may consider ordinary or extraordinary. I keep recalling my grandmother who simply refused to go to hospital and accepted only the treatment which she could receive at home. In her case it would have been an extraordinary burden to receive this sort of treatment in hospital.

In real life we will have to accept that patients need not ‘prove’ that for them the treatment is extraordinary. This they must do in their conscience if they wish to follow Catholic moral teaching. Can doctors refuse her wishes and force-feed or force-treat her. The answer is simply an unequivocal ‘no’ (unless there is an emergency situation where the patient is unable to express the wish). Doctors simply cannot treat without consent. That a law on advance directives is needed is clearly illustrated by a similar case mentioned recently where a patient refused dialysis but every time he entered hospital he was unconscious and doctors, being trained to save lives, gave him the treatment even though they knew that the patient did not want it. We have to come to terms with these things and legal guidance on the part of the state combined with moral guidance (to reaffirm the faith and the teaching) can create less difficulty in such situations. We have to accept that some illness is so burden some that patients refuse all treatment. It cannot be us to decide what is ordinary and what is not; this would clearly drive us away from existent moral teaching as well.

Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta. He is also

former president of the Malta College of Family Doctors.