CA 1: Competency Appraisal

San Pablo Colleges

College of Nursing

HEALTH CARE ETHICS

Module I:

Principle of Ordinary and

Extraordinary Means

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CA 1: Competency Appraisal

Module I: Principle of Ordinary and Extraordinary Means

Learning Objectives

To Conduct ethical
assessment in a given
case scenario.

Overview

Ordinary measures are those that are based on medication or treatment which is
directly available and can be applied without incurring severe pain, costs or other
inconveniences, but which give the patient in question justified hope for a
commensurate improvement in his health. Extraordinary measures are those that are
based on medication or treatment which cannot be applied without incurring severe
pain, costs or other inconveniences. Their application, however, would not give the
patient any justified hope for a commensurate improvement in his health.

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ENGAGE:

What are extraordinary measures?

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What are ordinary measures?
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I. EXPLORE

Ordinary care is obligatory, but can become extraordinary care under certain situations.
Extraordinary care is care whose provision involves a disproportionately great burden on the
patient or community, and hence is not morally obligatory.
that one is obligated to preserve his or her own life by making use of ordinary means, but is
under no obligation to use extraordinary means

Ordinary means
 Reasonable hope of benefit/success
 Not overly burdensome
 No risks
 Financially manageable
 Reasonable

Extraordinary means
 No reasonable hope of benefit/success
 Overly burdensome
 Presents risks
 Not financially manageable
 Inappropriate

“Ordinary means are all medicines, treatments and operations which offer a reasonable hope of
benefit and which can be obtained and used without excessive expense, pain or other
inconvenience” (Kelly 1951 , 551). Ordinary means are morally obligatory. So if the treatment does
not offer reasonable hope, is excessively expensive, or is inconvenient, then it would be
classified as an extraordinary intervention and would only be optional and not be morally
obligatory—a conclusion which can give peace of mind to the family who may be facing a
dilemma as to what is the correct course of action to take.

Determine whether the cases involve ordinary care or extraordinary care, and whether the
decisions given would be legal or illegal:

1. An infant is born with Down’s syndrome, indicating probable mental retardation. He

needs very low-risk surgery for an easily correctable intestinal defect. If untreated the

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baby will not be able to retain food and will die. The parents refuse surgery, stating that
the mental retardation will mean a less than meaningful life for the baby.

Answer: This case involves ordinary care; illegal decision: Parents may not refuse
ordinary care; the refusal of surgery would result in the proximate cause of death for the
child they have a legal duty to protect. Courts, however, usually have ruled in favor of
parents’ refusal.

2. A seven-year-old girl, auto-accident victim with severe internal bleeding, needs an

immediate blood transfusion to prevent death. Her parents refuse consent because blood
transfusions are forbidden by their religion (Jehovah’s Witnesses).

Answer: This case involves ordinary care; illegal decision: Parents may not invoke their
right to free exercise of religion to refuse lifesaving care for their child, for that would be
a violation of the child’s unalienable right to life, which takes precedence over all other
fundamental rights.

3. A 50-year-old woman is dying of cancer. She has only a few days to live. She has severe
anemia due to the cancer. Even though a blood transfusion is the usual treatment for
severe anemia, the decision is made not to give it.

Answer: Extraordinary care: This is an example of a treatment that is ordinary care in

most instances but becomes extraordinary care due to the circumstances of the particular
case. The transfusion would not be effective against the advanced cancer and would be
burdensome to the patient. Legal decision: Extraordinary care is not obligatory.

4. An 87-year-old incompetent woman with congestive heart and kidney failure has primary
cancer of the intestine. Surgery is the usual treatment for such cancer, but the family and
doctor decide against it.

Answer: Extraordinary care: Because of the advanced age and serious medical condition
of the patient, the surgery that might be considered ordinary care becomes extraordinary

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care because of its high risk under these circumstances. Legal decision: Extraordinary
care is not obligatory.

5. A 45-year-old man has a bleeding ulcer for which he needs a blood transfusion. He
refuses treatment because of religious beliefs which forbid transfusions of blood.

Answer: Ordinary care; legal decision: Competent adults have the right to refuse even
lifesaving treatment involving ordinary care under the right of bodily integrity and
intangibility. In addition, this patient also had the right to refuse under the free exercise of
religious right.

EXTENSION:

Ordinary or Extraordinary?
How can we know when a treatment is ordinary (thus morally obligatory) or extraordinary (only
optional)? “by studying the type of treatment to be used, its degree of complexity or risk, its cost
and the possibilities of using it, and comparing these elements with the result that can be
expected, taking into account the state of the sick person and his or her physical and moral
resources” (Sacred Congregation for the Doctrine of the Faith 1980 , part IV).
In determining whether a treatment is ordinary or extraordinary one should not merely consider
the degree of technology involved. It would be erroneous to state that “the treatment is ordinary,
but the family could not afford it.” If the family cannot afford it, then the treatment is not
ordinary but extraordinary. Ordinary (or extraordinary) is not simply a technical explanation of
the complexity of a treatment, but rather a description of the overall set of circumstances
including the treatment proposed, the burden imposed, the degree of success, pain incurred, as
well as the financial situation of the patient and family. For patient A, kidney dialysis can be
“extraordinary” because it is not available in his geographical location and to receive it three
times per week would result in an insurmountable travel burden. For patient B, the same dialysis
may be available locally but be “extraordinary” because the cost may be beyond the available
resources of the family. For patient C, dialysis may be accessible and affordable, but having a
minimal chance of success it can be deemed “extraordinary.” In some ways a dynamic and real-
time analysis of the patient and his or her medical situation needs to be performed. On day one of
a sickness, a family could have funds to pay for a ventilator (so it could be “ordinary”); but on

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day 10 their funds may be exhausted and thus the same treatment (a ventilator) can become
extraordinary. Or a patient receiving chemotherapy may tolerate the first round of drugs and
expect a reasonable chance of success. But if the cancer proves resistant, further rounds of
chemotherapy, which are much less likely to cure and more likely to become increasingly
burdensome for the patient, would be “extraordinary” and thus not obligatory. Further examples
could be given but the point has been made – the situation of a sick person needs to be
continually re-assessed, and what is judged “ordinary” treatment may later become
“extraordinary.”

EVALUATION:

Give examples of ordinary and extraordinary means in hospital setting.

Ordinary Means
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Extraordinary Means
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