Moral Decisions

At any moment, his beeper may call Dr. Daniel P. Sulmasy, O.F.M., to a terminal teenage cancer patient, an elderly man suffering a heart attack, a premature baby on life support or a depressed patient asking for removal of a respirator.

The array of conditions he deals with is unusual in a medical profession of increasing specialization, but Dr. Sulmasy, 43, is not your average physician. He is a Franciscan brother who heads the new John J. Conley Department of Ethics at St. Vincent's Hospital and Medical Center in Manhattan. In his daily rounds, he meets with spouses and other relatives as often as he does with patients. He identifies and explains the key moral issues to help the persons involved make informed decisions regarding life-sustaining care.

The growing complexity of technology at the beginning and the end of life, and the danger of money and machines taking precedence over patients, make his ethics speciality a necessity. He brings to the field a unique perspective as a doctor and a religious brother, combining knowledge of the latest medical advances and the traditional wisdom of the Church; the practical outlook of a clinician and the compassion of a Franciscan.

The medical and religious man are united in a view of the human person as sacred and transcendent, made in the image of God and deserving of respect and reverence at all stages of life. Dr. Sulmasy points out that this view of the person has informed from the beginning the practice of medicine in the West, which holds the basic conviction that patients should be healed, not harmed.

"Ethics is so deeply entwined with medical care," he said in a recent interview. "Usually the moral decision is the medical care--it sets the whole direction of treatment. On the other hand, you can't understand the moral issues without understanding the medical issues."

Responding to the charge that his specialty involves an ivory tower view of medicine, Dr. Sulmasy said, "Ethics is a most practical discipline. It addresses the question, 'What do I do?' "

Do medical ethicists tend to overstep their bounds, he was asked. "We're not the God squad. We do not tell people what to do. We try to help people, as far as we can, to make the right decisions in what are often very difficult circumstances," he explained.

He said the Church's stand in medical ethics often is misunderstood or misrepresented. Catholic teaching does not require that a patient be kept alive at all costs for as long as possible.

"People today are being presented with a false dichotomy," he observed. "They think either they've got to die tethered to some machine, wracked with pain, kept alive longer than is reasonable or merciful, or else they must go to Oregon and be helped to commit suicide. But the Church faithfully has maintained a middle ground."

That ground is formed by recourse to expert prudential decisions about the benefit that is likely with any given treatment in relation to the burden the treatment will place upon the patient. This weighing of treatment and benefit has been a formal part of Catholic health care since at least the 17th century, he said.

Pope Pius XII developed the tradition in this century by speaking of ordinary care, which must be provided, and extraordinary care, which may be declined, he added.

"We maintain a firm opposition to euthanasia and suicide but at the same time we can withhold life-sustaining treatment in some cases," he said. "We can treat people's pain even if the medication would slightly hasten the patient's death, as along as the intention is to eliminate the pain and not the person with the pain.

"This is a sane, rational way to provide good, quality health care that anybody, not just Catholics, would want to receive.

"We believe in the sacredness of human life but also in the resurrection of the body," he continued. "But we always have to assure that no action has as its intent the death of the person."

His medical school thesis is titled "Killing and Allowing to Die."

"There's a big difference," he commented, pointing to the volume on his office shelf.

Putting the ethical principles into practice in a hospital setting, with emotions of loved ones running high, demands all his training as a physician, brother and doctor of philosophy.

A recent case involved an elderly man with advanced cancer whose wife had rushed him to St. Vincent's with a desperate request that all measures be taken to keep him alive. Fluid was drained from the patient's distended abdomen, but doctors determined that no medical treatment would reverse the cancer. The patient was terminal.

"The wife's request for treatment at any cost was a call for therapy that the staff did not think would be effective," Dr. Sulmasy said. "There was a great deal of tension over this."

He received a call in the morning and by early afternoon he had spoken briefly with the wife and gathered a committee of physicians and a hospital attorney.

"The initial meeting with the wife was quite stressful for me. She was very distraught," he recalled. "At this point, her husband was barely conscious. She was refusing to allow him to receive morphine that would help relieve his pain and labored breathing."

Doctors found that the patient's blood was not clotting and placing an IV needle might cause complications. The medical staff was asking for her to consent to a do-not-resuscitate order (DNR), but the wife saw this as a betrayal of her husband and refused.

Dr. Sulmasy sat down with her to explain that treatment would not improve her husband's condition and would likely make it worse. The best medicine could do was to keep him pain-free and comfortable and allow him to die in peace.

"I had to reassure her that this would not be considered euthanasia...At a certain point, it's best to let nature take its course," he said. "There was a difficulty in letting him go. But the most compassionate thing she could do would be to let him go."

The wife eventually consented to the DNR, and the man died peacefully the following evening.

Other cases involve well-meaning requests from loved ones to stop life-sustaining treatments which the hospital must refuse because there is a possibility for improvement of the patient.

Dr. Sulmasy grew up on Long Island and attended St. Anthony's High School, now in South Huntington. The seeds of a vocation were planted by the Franciscan Brothers there and grew as he went through undergraduate studies and medical school at Cornell University in Ithaca. After earning his medical degree, he entered the Franciscans' Holy Name Province in Manhattan. He lives in St. Francis Friary on West 31st Street.

"I think I have a Franciscan soul," he remarked. "St. Francis' conversion came when he embraced his first leper. The early Franciscans were all nurses for lepers. This is Catholic health care at its best."

He came to St. Vincent's Medical Center last year from Georgetown University to found the ethics department. He does not head a committee of ethics, he pointed out. Many hospitals, including secular ones, have such committees. St. Vincent's is unique in that it has raised ethics to the status of a medical department, on a par with any other department such as oncology, surgery or gynecology.

Dr. Sulmasy holds a chair endowed by the Sisters of Charity, who own St. Vincent's, and also teaches medical ethics at New York Medical College in Valhalla, which is affiliated with the archdiocese.

The Catholic character of St. Vincent's once was assured by the presence of many religious sisters, he said. With the direct influence of the sisters less today, he noted, the ethics chair is "a way for them to continue their presence here by making ethics as important and as endowed as any other medical department."

He stated, "At some level, medicine is ministerial. Visiting the sick is a corporal work of mercy. The work I do is what I call pre-evangelization--bringing people to confront these weighty questions, these ultimate questions, the answers to which, we believe, are found in the person of Jesus Christ."