Abstract
The traditional distinction between ordinary, i.e., obligatory means to preserve life and extraordinary, non-obligatory means is an especially useful tool for HECs in today's secular pluralist health care system, because it gives factors that can override the prima facie good of preserving the patient's life. I first indicate the need for such a tool. I then demonstrate the present misunderstanding of the distinction and give its proper understanding. Finally, I show the applicability of the distinction for HEC deliberations about three important types of cases: the conscious, irreversibly but not terminally ill patient who requests cessation of curative treatment; the provision of artificial nutrition and hydration to permanently vegetative patients; and the allotment of intensive care and other scarce medical resources.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Veatch, R. Death, Dying, and the Biological Revolution, 1st ed., New Haven: Yale University Press; 1976. “That it is morally expendable because it is unusual seems preposterous. In the same light it does not seem reasonable to require a treatment simply because it is usually provided. If that were the case no change in policy could ever take place.... Ordinary must have some relation to usual. That, at least, is its common meaning outside of medical ethics, but reference to its common use simply confuses its meaning in the medical context today” (pp. 107, 110).
Letsch SZ. Levit KR., Waldo DR. National health expenditures, 1987. Health Care Financing Review. 10 (1988).
Health Care Financing Administration, Office of the Actuary, Division of Health Cost Estimates. National health expenditures, 1986–2000. Health Care Financing Review 8; 1987.
Scheiber, GJ, Poullier, JP. International health care spending. Health Affairs. 5: 111–22; 1986. In 1984 $U.S. as PPP: Greece, $287 per capita health ($6,300 per capita income); Japan, $818 per capita health ($12,419 income); U.S., $1,637 per capita health ($15,357 income).
World Health Statistics Annual 1988. Geneva: World Health Organization; 1988: 80–83. Life expectancy at various ages (males):
Knaus, WA, et al.. A comparison of intensive care in the U.S.A. and France. Lancet. 2 (September 18): 642–46; 1982.
Berenson, RA. Intensive Care Units (ICUs): Clinical Outcomes, Costs, and Decisionmaking. Washington, D.C.: Congress of the United States Office of Technology Assessment: 1984.
The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to Forego Life-Sustaining Treatment. Washington, D.C., U.S. Government Printing Office; 1983.
Beauchamp, T., Childress, J., Principles of Biomedical Ethics New York: Oxford University Pess; 1989. They introduce additional distinctions into their reconstrual of the traditional distinction in terms of obligatory and optional, viz., of the optional as either morally neutral or as morally heroic, and of a third alternative to the former two, viz., of the wrong, which need not concern us here (p. 153).
Pius XII, Pope, Le Dr. Bruno Haid, Acta Apostolicae Sedis. 49; November 24, 1957; 11. Engelhardt Jr., HT, Bole TJ. Entwickelungen der medizinischen Ethik in USA: die Verfuehrung durch die Technik und der Irrtum einer Lebenserhaltung um jeden Preis [Developments in medical Ethics in the U.S.: Seduction by Technology and the Vice of Attempting to Save Lives at Any Price]. Arzt und Christ. 1990 (in press).
McHugh, JT. Principles in regard to Withholding or Withdrawing Artificially Assisted Nutrition/Hydration. Camden: Roman Catholic Diocese of Camden Communications Center, August 1989.
Council on Scientific Affairs and Council on Ethical and Judicial Affairs. Persistent vegetative state and the decision to withdraw or withhold life support. Journal of the American Medical Association 263: 426–30; (January) 1990.
Origins. 17: 546–47; January 21, 1988. The statement was drafted by the diocesian vicar for education, Rev. Robert McManus. The Case was decided in the plaintiff's 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).
Grisez, G. Should nutrition and hydration be provided to permanently unconscious and other mentally disabled persons? Issues in Law & Medicine 5: 181–96; 1989.
Lindeboom, GA. Descartes and Medicine. Amsterdam: Rodopi N.V., 1978. Lindeboom reached his conclusion by surveying Descartes' writings with regard to how to maintain one's health. Abbe Picot, who had lived with Descarte 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 an external (étrangère) and violent cause as that which deranged his ‘machine’ in Sweden, he would have lived five hundred years” (p. 95). (Adam C.), Tannery P. (eds.). Oeuvres de Descartes. Paris: Leopold Cerf; 1909; vol. XI, p. 671.
Bole, TJ, Intensive Care Units (ICUs) and Ordinary means: Turning Virtue into Vice. Linacre Quarterly. 57: 68–77, February 1990. This article contains some of the sources in Roman Catholic moral theology, dating from the 16th century, for these distinction.
Knaus, WA, Zimmerman, JE, Wagner, DP, et al., APACHE-Acute Physiology and Chronic Health Evaluation: A Physiologically Based Classification System, Critical Care Medicine 9: 591–97; 1981.
Knaus, WA, Draper, EA, Wagner, DP, et al., APACHE II: A Severity of Disease Classification System. Critical Care Medicine 13: 818–29; 1985.
I am indebted to the observations of K. Ritchie, M.D., M.A., for the suggestions made in this paragraph, as well as about this paper as a whole.
Rights and permissions
About this article
Cite this article
Bole, T.J. The ordinary-extraordinary distinction reconsidered: A moral context for the proper calculus of benefits and burdens. HEC Forum 2, 219–232 (1990). https://doi.org/10.1007/BF00122604
Issue Date:
DOI: https://doi.org/10.1007/BF00122604