Ordinary and Extraordinary Care

Ordinary care is always obligatory. Extraordinary care is care whose provision involves a
disproportionately great burden on the patient or community, and hence is not morally obligatory.
Ordinary means- all medicines, treatments and operations that offer a reasonable hope of benefit and
which can be obtained without excessive response, pain, or other inconvenience.
Extraordinary means- all medicines, treatments and operations that cannot be obtained or used without
excessive expense, pain or other inconvenience or which, if used, would not offer a reasonable hope of
benefit.
Personhood
One rather controversial line of reasoning that seems appropriate for cases involving patients in a
persistent vegetative state with no hope for recovery is the examination of the requirements of
personhood. While we generally agree that human beings have certain rights and privileges and that these
rights are not extended to rocks, trees, or animals, what is the essential difference? What types of beings
can be thought of as bearers of rights? What types of beings can be thought of as persons?
Philosophers Joseph Fletcher and Joel Feinberg attempted to define characteristics to be able to consider
as bearer of rights and came up with a criteria:
1. One who could be said to have interests: a person for whom something can be said to be good for
his/her own sake
2. One who has cognitive awareness; a being of memories, expectations, and beliefs.
3. One who is capable of relationships, interpersonal relationships seem to be at the very essence of
what we idealize in truly being a person.
4. One who has a sense of futurity. How truly human is someone who cannot realize there is a time
yet to come as well as a present. The words What do you want to become only makes sense in
relation to a person.
Advanced Directives
In 1983, Nancy Cruzan lost control of her car and was thrown into a ditch. Although she was resuscitated
at the scene of the accident, she never regained consciousness. She was diagnosed as being in a persistent
vegetative state and Physicians said that she could live up to 30 years with the support of feeding tubes.
The family requested to remove the feeding tubes and allow Nancy to die but the Missouri Rehabilitation
Center refused their request so the family took the case to the lower court which ruled their favor. Thus
affirmation was overturned by the State Supreme Court of the United States. In its decision, the Court
upheld the Missouri Supreme Court position that not even the family should make choices for an
incompetent patient in the absence of clear and convincing evidence of the parents wishes. The Court
ruled that the states do have these rights for the following reasons:
1. The state has the right to assert an unqualified interest in the preservation of human life
2. A choice between life and death is an extremely personal matter
3. Above can occur when incompetent patients dont have loved ones available to serve as surrogate
decision makers
4. The state has a right to express an unqualified interest in the preservation of human life
Although the Supreme Court held to a narrow focus in the Nancy Cruzan case, several critical aspects
were reinforced by the decision. First, the Court upheld the concept that competent individuals could
refuse life-sustaining treatment. Second, it made no legal distinction between tube feeding and other life-

sustaining measures. Food and water may be withheld when either of the two following conditions are
met.
1. The treatment is futile. In cases where all efforts to provide nutrition would be ineffective and
cause pain, e.g., those patients where the cardiac status is such that any IV fluids would overload
the heart.
2. No possibility of benefit. While it is most often reasonable practice to provide nutrition and
hydration, in those cases where the family and caregivers agree that the practice offers no benefit,
such as the PVS case, there should be no barrier to discontinuance.