Minnesota’s bishops raise concerns about "end of life" medical treatment form

Among the most difficult medical decisions are those that must be made when patients can no longer speak for themselves. For that reason, more people are turning to various forms of “advance directives” to outline their wishes regarding medical treatment ahead of time.

Minnesota’s bishops, however, recently issued a new pastoral statement raising ethical concerns about an end-of-life medical care form known as “Provider Orders for Life-Sustaining Treatment,” or POLST.

“We believe that there are sufficient and significant ethical concerns that argue against its use for advance-care planning,” the bishops said in a statement titled “Stewards of the Gift of Life.”

Like advance directives, POLST forms aim to help ensure a patient’s wishes for medical care are carried out in the final stages of life. But, while advance directives allow patients to state treatment preferences, POLST forms constitute standing medical orders signed by a physician or another health care practitioner who can issue such orders.

POLST forms are increasingly being used around the country and were endorsed by the Minnesota Medical Association in 2009. Many hospitals and long-term care facilities — including Catholic health care providers — are using them.

Various concerns

A joint study committee composed of members of the Minnesota Catholic Conference, the public policy voice of the state’s bishops, and the Catholic Health Association of Minnesota studied the issue in depth for more than a year to give the bishops guidance on the issue, said Jason Adkins, MCC executive director. Committee members included doctors, nurses, ethicists, lawyers and health care providers.

The archdiocesan Commission on Biomedical Ethics was also consulted on the issue, he said.

One concern the bishops have about POLST forms is that they fail to acknowledge that patients can’t truly give informed consent for treatments when the variables surrounding a future medical condition are unknown.

“From a Catholic perspective, making a morally sound decision regarding end-of-life care calls for informed consent based on information related to the actual circumstances and medical conditions at a particular moment,” the bishops said.

“For both patients and providers, it is difficult to determine in advance whether specific medical treatments will be absolutely necessary or optional,” they note. “Though we have some ability to determine a person’s course of illness, we do not have absolute certainty.  Therefore, any tool created to guide medical management must take these predictive limitations into consideration.”

POLST forms risk oversimplifying the medical-decision making process, the bishops said.

“Decisions depending upon factors such as the benefits, expected outcomes, and the risks or burdens of the treatment are oversimplified by ‘one-size-fits-all’ checkboxes, without the benefit of clinical context,” they said. “As a result, using POLST bears the risk that an indication may be made to withhold treatment that, under certain unforeseen circumstances, the patient would want to receive.”

Teresa Tawil, a gerontological nurse practitioner working in the Twin Cities, said the biggest problem with a POLST form from her perspective is the potential for it not to be current with a patient’s changing health care status.

“This is why a prewritten document has its limitations,” said Tawil, who served on the MCC-CHA study committee and is a member of St. Raphael in Crystal. “A designated power of attorney who acts out of Christian love for the patient and is educated in the patent’s current medical situation and . . . the overall burden of illness is crucial to guiding morally sound care.”

The bishops’ statement raises additional concerns about POLST. Among them are:

• The forms might be used for patients who are not terminally ill as a form of assisted suicide or euthanasia.

• The form permits but does not require a patient’s signature (or the signature of a legally designated health care agent), and thus raises concerns about having a patient’s true informed consent for important decisions.

• POLST lacks a conscience clause for health care professionals who may have concerns about medical orders they are asked to fulfill.

Alternatives available

In discouraging the use of POLST forms by Catholics and Catholic health care providers, Minnesota’s bishops point to better alternatives, including the Minnesota Catholic Health Care directive and accompanying guide. The directive meets the state’s legal requirements and reflects the Church’s teachings on end-of-life care. (The form and guide can be accessed at http://www.mncc.org/resources/mn-catholic-healthcare-directive-2.)

In “Stewards of the Gift of Life,” the bishops also support the appointment of a health care agent who can speak for a patient and act in his or her best interests. And they call for “renewed efforts to educate the Catholic community and other interested persons in the rich tradition of our Catholic teaching on end-of-life care.”

“We need to start having these conversations with our family members, with our loved ones, as uncomfortable as they may be,” Adkins said. “We need to express our own wishes and make sure that when we are pursuing end-of-life care that it is consistent with our own Catholic faith and objective moral norms.

“And,” he added, “we need to look for people in our lives who can help us make those decisions. Otherwise, we leave our families in a difficult position of trying to discern what our wishes might be or how to handle these things.”

The MCC said a future goal is to develop a resource that lays out in “a more substantive and developed way” a Catholic perspective on end-of-life care that helps people understand the various resources available to them.

Interview: Jason Adkins, Executive Director of Minnesota Catholic Conference

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In the Catholic Servant newspaper, By David Hottinger
[Editor’s Note: In March of this year, Jason Adkins, J.D., was appointed the executive director of the Minnesota Catholic Conference. “The Catholic Servant” recently interviewed
him.]

“The Catholic Servant”: Briefly, what is the Minnesota Catholic Conference (MCC)?

Jason Adkins: The MCC is the public policy voice of the Catholic Church in Minnesota. It represents all of Minnesota’s bishops — and by extension, the whole Church in Minnesota— at the Legislature to advocate for laws that promote human dignity and the common good; that defend marriage and family life; and that promote other tenets of Catholic social
doctrine.

“The Catholic Servant”: As an organ of the Church, should you really be meddling with politics?

Jason Adkins: The MCC assists the bishops in their teaching office of transmitting the Church’s social doctrine to the faithful, but also by bringing the Church’s voice into the public arena. The Church’s primary responsibility is not to provide technical solutions to every conceivable public policy problem, but instead to help form the consciences and worldview of Catholics so that they can bring Catholic teaching into the public square.
But oftentimes, the Church will step in and make prudential judgments that certain public policies are necessary to promote the common good of all society, particularly families, which are the first and natural cornerstone of civil society. Still, the bishops’ primary responsibility in the realm of politics is to provide the ethical and moral framework within which the laity and politicians can develop specific answers to difficult public policy questions.
One common misunderstanding among Catholics and the general public alike is why the Catholic Church, a religious institution, has any role or any say in the formation of civil laws. This misunderstanding often generates a certain hostility when the Church participates in the public square.
Yet the Church has a responsibility to society as one of its principal actors to speak out and share its wisdom, collected over the centuries, about the principles that should guide public policy decisions. The Church proposes; she never imposes.
Like any other institution or political actor, the Church must convince the public of the wisdom of her positions. But she is certainly not excluded from participation simply because of her religious identity. Martin Luther King, Jr. was not excluded from speaking about civil rights because he was a Baptist minister and used theological arguments in his quest for a more just society.

“The Catholic Servant”: Is it ever the case that the MCC advocates for a policy which reasonable Catholics could differ over?

Jason Adkins: Often, when the MCC advocates for or against certain public policies, some degree of prudential judgment is involved. But some issues are more clear-cut.
The Church and the bishops have a responsibility to speak whenever the institutional integrity or mission of the Church is threatened. Similarly, it is compelled to speak when there are laws proposed that specifically undermine human dignity or threaten the common good of society.
In any given session of the Legislature, thousands of bills are authored and in the vast majority of instances, the bishops do not take a position for or against them. Yet there are some instances in which the bishops, through the MCC, will counsel legislators and other officials to enact a specific piece of legislation because they deem it so fundamental for promoting human dignity and the common good. Examples of such issues include many types of abortion restrictions;
ensuring that cuts are not made to assistance programs for children, elderly, and the disabled;
comprehensive immigration reform; and seeing that parental choice in education is expanded,
especially for the poor.
When making these determinations, the bishops and conference staff must view each piece of legislation in light of the principles of Catholic social doctrine, specifically the protection of human dignity, promoting the common good, along with the twin principles of solidarity and subsidiarity.

“The Catholic Servant”: You mentioned the “M” word: Marriage. With the Marriage Amendment on the ballot next fall, what will the MCC do in the interim?

Jason Adkins: The MCC is supporting a statewide ballot campaign called Minnesota for Marriage which seeks to encourage other Minnesotans to vote for an amendment to the Minnesota constitution defining marriage as the union of one man and one woman.
The MCC will be working with other organizations supporting Minnesota for Marriage to build a statewide, grassroots campaign composed of many volunteers who will register voters, knock on doors, and seek to convince others to vote for the amendment. The MCC, for its part, will be working with Catholics of every diocese to help build this campaign.
We know it is not enough for us to simply get enough votes to pass the amendment. We also have to educate Catholics about the vital role that marriage plays as a cornerstone of a healthy society. If we don’t take this opportunity to educate and inform Catholics of the importance of the institution of marriage and the role it plays in nurturing healthy families and healthy children, then over the long term we will not be able to sustain laws protecting traditional marriage.
Therefore, it is absolutely vital that Catholics take on their responsibility as faithful citizens to educate themselves about the issue and help in whatever way they can with the marriage amendment campaign.

“The Catholic Servant”: And why should Catholics— why should anyone—be concerned about preserving traditional marriage?

Jason Adkins: Fundamentally, what’s at stake are two competing arguments about the nature of marriage. There is a movement around the country and around the world to redefine civil marriage laws. The public needs to be well aware that those seeking to promote what’s called same-sex marriage are not out to create a separate institution that same-sex couples can enter into. Instead, people opposed to traditional marriage seek to redefine marriage for the rest of society.
And despite their very vocal presence in the culture and in the media, the actual number of
these advocates is very small. According to the census, only one percent of all couples in
Minnesota are living together in same-sex relationships. Such a small minority of the population
should not have the ability to redefine a bedrock social institution.
The consequences of redefining marriage will be profound. Redefining marriage redefines
parenthood and the family. By extension, redefining marriage will reshape, in radical ways, civil society.
Marriage as an institution in civil law is ordered toward the nurturing and well-being of children and not around the supposed happiness of adults. When proponents of redefining marriage say that government has no business telling them who they can love, they are absolutely correct. But they have missed the point of the civil institution of marriage altogether. It is not about regulating relationships between consenting adults. It’s about the care and wellbeing of children.
Those who seek to redefine marriage want to turn the institution into a system of government-
sanctioned love licenses. [If that happens] people will quickly see this counterfeit version of marriage for what it is and decline to enter into it. Thus, the practical effect of redefining civil marriage will be to redefine it out of existence.

“The Catholic Servant”: And what can you tell us about our opponents in this fight?

Jason Adkins: Those opposed to the marriage amendment are well-financed and well-organized. The movement to end traditional marriage laws is led by persons whose sexuality, whose very identity, is wrapped up in the issue. So they will focus everything they have on the campaign. They have been working at this for years and already have the framework in place to run a
campaign. Not only that, but their supporters hold the commanding heights of our culture;
in academia, in politics, even in the entertainment industry. It presents quite a hurdle to overcome.
Our side, on the other hand, is disadvantaged in the sense that the groups involved in promoting
the marriage amendment do a lot of other things besides just marriage policy. Additionally, we have the challenge of putting a statewide campaign together from scratch.
But we are confident that we can win because the arguments are on our side. We just have to show the majority of Minnesotans—who know in their gut that just as the sun rises in the east, marriage is between one man and one woman; that supporting traditional marriage is not bigotry or discrimination; that you can be kind to your neighbor without
being forced to redefine the bedrock institution of society. To ultimately succeed, however,
we will need all Catholics’ prayers, hard work, and support.

David Hottinger is a freelance writer from the Twin Cities who is attending the University of Minnesota Law School.

This article was funded by the St. Benedict Chair of Writing sponsored by an anonymous patron of The Catholic Servant.
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