Distinctions to be Made

Radoslav Lojan
Ottawa, ON Canada (01/02/2008)
Reproduced with Permission

People use language in many different ways. Language is a very necessary part of our life and even if we state facts or ask questions, it may change our lives. Language also classifies and distinguishes the realities that we encounter. I personally observed from the beginning of my academic research in bioethics (since 2001) that many bioethicists today are using many medical or ethical terms without clarifying their meaning. These terms have to be clarified before any ethical judgments are offered. In this paper, I will examine four important pairs of terms and distinctions, which in my judgment are important for bioethics today.

1. Ordinary and Extraordinary Means/Proportionate and Disproportionate

Advances in medical technology in the present age and various legislative proposals representing different views on medical-ethical problems in determining the morality of conserving, prolonging, or terminating life all today emphasise a growing apprehension in contemporary medical ethics. Our focus in this paper is specifically based upon Roman Catholic traditions, which among others distinguish between ordinary and extraordinary means of preserving life.1

Pope Pius XII gave clarity to the distinction between ordinary and extraordinary means in his November 24, 1957 address to Catholic physicians and anaesthesiologists:

Normally one is held to use only ordinary means -- according to the circumstances of persons, places, times and culture -- that is to say, means that do not involve any grave burden for oneself or another. A stricter obligation would be too burdensome for most people and would render the attainment of the higher, more important good too difficult. Life, health, all temporal activities are in fact subordinated to spiritual ends. On the other hand, one is not forbidden to take more than the strictly necessary steps to preserve life and health, as long as one does not fail in some more serious duty.2

In Roman Catholic Moral Theology today, some ethicists or moral theologians instead distinguish between "proportionate" and "disproportionate" means as alternative terms to indicate the same moral distinction denoted by the traditional moral terms. These terms define the following means in regards to the human person:

  1. If the means offers the patient "proportionately" more benefits than burdens the means of conserving life are morally obligatory.
  2. If the portion of hardship is greater than the promised benefit to the patient, the means are "disproportionate" and without moral obligation.3

In traditional medical and ethical terminology, "ordinary" means are such things that can be obtained and used without great difficulty; by "extraordinary," they mean everything which involves excessive difficulty by reason of physical pain, repugnance, expense.4

Moreover, for a correct understanding and application it is vital to conduct a deeper examination according to different theologians. Deeper examination of the distinction between ordinary and extraordinary is offered by moral theologian Gerald Kelly, S.J. Kelly defines ordinary means as "all medicines, treatments and operations which offer a reasonable hope of benefit for the patient and which can be obtained and used without excessive expense, pain, or other inconvenience."5 Extraordinary means are "all medicines, treatments, and operations, which cannot be obtained or used without excessive pain, or other inconvenience, or which, if used would not offer a reasonable hope of benefit."6 Kellys distinction is very clear and very relative to changing circumstances with the patient being the one who decides the value of treatment.

The most important study of the development of ordinary and extraordinary principles comes from the doctoral dissertation of Daniel A. Cronin.7 Cronins definitions are very similar to Kellys and may even be considered simply as clarifications of Kellys: "Ordinary means of conserving life are those means commonly used in given circumstances, which this individual in his present physical, psychological and economic condition can reasonably employ with definite hope of proportionate benefit. Extraordinary means of conserving life are those means not commonly used in given circumstances, or those means in common use which this individual in his present physical, psychological condition cannot reasonably employ, or if he can, will not give him definite hope of proportionate benefit."8 Cronin in his thesis determines and also distinguishes between preserving and prolonging life. According to Cronin "in the matter of preserving life, there is greater obligation to use the available means. In applying the principles to a patient in PVS, we are dealing with preservation rather than prolongation of life."9

In fact, there are many other moral theologians who have reviewed this distinction. Gemanin Grisez and Joseph M. Boyle have pointed out that "ordinary and extraordinary are introduced as ethical or theological distinction with little doubt that their use in the legal arena is far from adequate."10

2. Action and Omission

Another commonly used distinction is between action and omission. According to The New Westminster Dictionary of Christian Ethics, "the word action is derived from the Latin agree, which means "to do," and is commonly used in ethics."11 Omission on the other hand is according to The New Westminster Dictionary of Christian Ethics "the failure to do that which one has a duty to do. Omission is not the same as inaction or passivity since it may be psychologically active and intense. Omission also connotes deliberateness."12

This distinction still requires deeper examination. A major problem according to ethicist Devettere "arises when the distinction is used in situations where the foreseen outcome is not wanted or desired, and a distinction is made between actions and omissions giving rise to the unwanted outcome."13

The action and omission distinction appeals to different pathways. According to Gleeson, "moral actions can only properly describe in relation to their agents? practical reasoning, intentions, and choices. From the agent perspective, one can successfully intend to bring about death as much by doing nothing as by doing something. In terms of moral responsibility, doing nothing is in truth doing something, depending on ones obligations and intentions. The priority of the agents perspective and intention does not make physical causality irrelevant to moral evaluation."14

Based on the wisdom of St. Thomas Aquinas, there are "three conditions in order that a person is charged with guilt in a situation which involves the omission of an act in impeding evil, or the placing of an act which causes evil, even though the final effects of evil are not intended:

  1. In some manner, at least in a confused way, a person must foresee the evil effect.
  2. A person must be able to prevent the evil either by acting or omitting an action.
  3. A person must be bound by some obligation to prevent the evil."15

According to Russell E. Smith, "the first condition is that the reason because nothing can be considered voluntary unless it is foreseen to some significant degree. Second condition is that it is within the power of the individual involved to omit or avoid the action or at least to render it ineffective. Third condition is that the individual must be obligated to prevent the action so that the bad effect does not follow."16

In summary, the distinction between action and omission is a very necessary one although the manipulation of language may serve as camouflage for any action. We have to remember that any omission can be as immoral as actions. Proper moral consideration in this difference may help us to be more responsible.

3. Intentionally Causing Death and Letting Die

Another distinction presented and evaluated here is called "intentionally causing death and letting die." According to Kevin O'Rourke, "through this distinction, people sometimes convey the notion that active euthanasia (inducing a cause of death) is morally wrong, but passive euthanasia (withholding care with the intention of letting a person die) is morally acceptable. But the intention of killing a person either by inducing the cause of death or by being passive and allowing death to occur is ethically unacceptable."17

This distinction is ever-present in health-care. The withdrawal of "artificial nutrition and hydration" [henceforth ANH] from a person is ethically acceptable only in extraordinary circumstances when life support will not benefit the patient and the intention of the caregiver is to do something morally good; that is, to cease doing something useless or to avoid inflicting a grave burden upon the patient. There are some other reasons when the withdrawal of ANH from a person is ethically acceptable:

  1. When treatments are considered futile. The most obvious example in palliative care environments is cardiopulmonary resuscitation.
  2. When the burdens and risks of treatment greatly outweigh the benefits.
  3. When treatments are not considered to further the patient's medical good.
  4. When treatments are not considered to further the patient's total good.
  5. When treatments are not available due to resource constraints.18

In summary, although the distinction seems rationally as a very clear one, it is not. A final effect is difficult not only for physicians, but for the patients family as well, and it should always be morally justified in all circumstances.

4. Direct and Indirect Results

All our actions invariably have results that we might call consequences, outcomes, or effects. Some of our consequences are expected and some not. On the other hand, there are some effects that are good and some that are not. As our concern here is primarily based on Catholic traditions, we will call it a "double effect." A double effect may also be easily described as performing an action in pursuit of a good end, although the action may also bring about bad results.

This principle of double effect has its historical roots in the medieval tradition, especially in the meditations of St. Thomas Aquinas (1225-1274) and has been evaluated for many years up to and including the present day. Christian understanding of the principle of double effect is based on the biblical understanding of the origin of evil in the world. This understanding comes from the Old Testament, especially from a book of Gn 3:4, NJB where humanity has rebelled against Gods love and because of this disobedience has to now live in a confused world. To find the right path is impossible without Christ and the Holy Spirit.

Traditionally, according to Gula, "the principle of double effect used the distinction of the direct and indirect intention because it regarded certain actions as intrinsically evil."19 Classical formulations of the principle of double effect require four conditions to be met if the action in question is to be morally permissible:

  1. The directly intended object of the act must not be intrinsically contradictory to ones fundamental commitment to God and neighbour (including oneself).
  2. The intention of the agent must be to achieve the beneficial effects and to avoid the harmful as far as possible (for example: must only indirectly intend the harm).
  3. The foreseen beneficial effects must not be achieved by the means of the foreseen harmful effects, and no other means of achieving those effects are available.
  4. The foreseen beneficial effects must be equal to or greater than the foreseen harmful effects.20

This principle is also known today as "the principle of proportionality, proportionalism, or proportionate reason."21

In summary, from a moral point of view we have to remember that we are responsible for direct or indirect effects. Prudent reasoning seems essential for any action or judgment.


In conclusion, it is always very important to understand in the bioethics today, specifically in any end-of-life cases, precise distinctions of important medical and ethical terms, like for example between "ordinary" and "extraordinary" or "proportionate" and "disproportionate" reason as alternative terms. Because of their differences, one should specify whether one is offering a general description of the availability of treatment or a specific ethical judgment based on effectiveness/ordinary intervention or grave burden/extraordinary intervention for a particular patient. All these distinctions are also used today in medical ethics to distinguish medical therapies as standard one from medical therapies which are innovative or experimental.


1 This distinction has been made first time in 1595, at the end of the High Renaissance, the Dominican theologian Domingo Banez. By the time of Juan Cardinal de Lugo (1583-1660) and Alphonsus Liguori (1696-1787), the terms "ordinary" and "extraordinary" are already known. See more, Eric J. MEIDL, "A case studies approach to Assisted Nutrition and Hydration," in The National Catholic Bioethics Quarterly, 6/1 (2006), p. 1. [Back]

2 PIUS XII, "Address to an International Congress of Anesthesiologists" (November 24, 1957), in AAS, 49 (1957), p. 1030. [Back]

3 See also for further study, WILLIAM MAY, Catholic Bioethics and the Gift of Human Life (Huntington, IL: Our Sunday Visitor Publishing Division, 2000), p. 257; Ron HAMEL, Making Health Care Decisions: A Catholic Guide (Liguori Publications, 2006), p. 10. [Back]

4 See Michael PANICOLA, "Catholic Teaching on Prolonging Life: Setting the Record Straight," in Hastings Center Report, 31/6 (2001), pp. 17 - 18. [Back]

5 Gerald KELLY, "The Duty to Preserve Life," in Theological Studies, 12 (1951), p. 550. See also Gerald KELLY, "The Duty of Using Artificial Means of Preserving Life," in Theological Studies, 11 (1950), pp. 203-220. [Back]

6 Ibid., p. 129. See also Gerald KELLY S.J., Medico-Moral problems (St. Louis, MO: Catholic Hospital Association of the United States and Canada, 1958), pp. 128-148, esp. p. 129. [Back]

7 See Daniel A. CRONIN, The Moral Law in Regard to the Ordinary and Extraordinary Means of Conserving Life (D. Thesis - Rome: Pontificia Universitas Gregoriana, 1958), pp. 1-142. [Back]

8 Ibid., pp. 127-128. [Back]

9 Ibid., p. 122. [Back]

10 Gemanin GRISEZ, Joseph M. BOYLE, Life and Death with Liberty and Justice (Notre Dame: University of Notre Dame Press, 1979), p. 257. [Back]

11 James F. CHILDRESS and John MACQUARIE, The New Westminster Dictionary of Christian Ethics (Philadelphia: Westminster Press, 1986), p. 8. [Back]

12 Ibid., p. 437. [Back]

13 Raymond DEVETTERE, Practical Decision Making in Health Care Ethics (Washington, D.C.: Georgetown University Press, 1995), p. 51. [Back]

14 Gerald GLEESON, "The withdrawal of life-sustaining treatment Ethics and law: principles and practice," in Bioethics Outlook, 14/2 (2003), pp. 3-4. [Back]

15 THOMAS AQUINAS, Summa Theologica, I-II (Taurini, Italia: Marietti, 1937), p. 71. [Back]

16 Russell E. SMITH, Conserving Human Life (Philadelphia, PA: National Catholic Bioethics Center, 1989), pp. 204-205. [Back]

17 Kevin D. O'ROURKE, "Medical Ethics Requires Accurate Distinctions," in The Center for Health Care Ethics newsletter, 11/1 (1989), p. 1. [Back]

18 Pravin THEVATHASAN, "Acts and Omissions at the End of Life," in The Catholic Medical Quarterly, 1/5 (2006), p. 3. [Back]

19 Richard GULA, S.S., Reason Informed by Faith - Foundation of Catholic Morality (New York: Paulist Press, 1989), p. 271. See also Joseph MANGAN, "An Historical Analysis of the Principle of Double Effect," in Theological Studies, 10 (1949), pp. 40-61. [Back]

20 Ibid., p. 185. For further studies, see also: Peter J. CATALDO, "The principle of the Double Effect" in Ethics & Medics, 20/3 (1995), pp. 1-3. [Back]

21 GULA, Reason Informed by Faith, p. 272. [Back]