Background

Aging with Dignity (AWD) is a non-profit organization that defends the rights of all people as they approach the end of life. It was founded in 1996 by Jim Towey, a close friend and advisor to Mother Teresa of Calcutta. Its Five Wishes program is America’s most popular resource for advanced care planning. It has helped millions of families plan for dignified end-of-life care.

AWD offers Finishing Life Faithfully: A Guide for Catholics on End-of-Life Care, as a companion document for Catholic users of the Five Wishes advance directive. The use of these two documents has been endorsed by numerous cardinals and bishops in the United States, including Archbishop Gregory Aymond, chair of the National Catholic Bioethics Center (NCBC) and Cardinal Timothy Dolan, a board member of NCBC. Bishop Michael Burbidge, chairman of the Pro-Life Activities Committee of the United States Conference of Catholic Bishops (USCCB), recommends the use of these popular AWD resources. In 2024, the USCCB Committee on Doctrine reviewed Finishing Life Faithfully and found nothing contrary to established Catholic teaching.

Unfortunately, a handful of Catholic ethicists and health care professionals remain critical of Five Wishes and do not recommend its use. Before addressing their concerns, it is crucial to establish the overwhelming areas of agreement between AWD and this small band of Catholic critics.

Areas of Agreement

1. Both oppose the legalization of assisted suicide and euthanasia; the use of POLST and MOLST forms as a substitute for doctor-patient interaction and health care proxy involvement; health care decision making driven by fear; and the use of quality-of-life metrics to measure the value of human life.
2. Both stress the importance of appointing a qualified health care proxy who cares deeply about the patient and will make decisions in accordance with the known wishes of the patient and both provide health care proxy and living will forms.
3. Both advise the use of a living will to provide written guidance to a health care proxy as he or she makes treatment decisions that honor the patient’s wishes.
4. Both urge patients to cross out sections in pre-printed advance directives that are contrary to patient wishes.
5. Both encourage a health care proxy of a Catholic patient to be educated on Church teaching on end-of-life care.
6. Both believe artificial nutrition and hydration are considered “ordinary care” and in most cases morally obligatory for Catholics.

AWD Responses to Objections

Objection 1: Choosing a health care proxy, a living person, to make decisions in real time for a person unable to communicate, is preferable to Five Wishes which relies on written instructions.

Misleading. The very first wish of Five Wishes is a health care proxy appointment form. Five Wishes emphasizes the primacy of the proxy decision even if it conflicts with the written instructions of the patient, a rare feature for advance directive forms. There is no disagreement here.

Objection 2: People should be wary of living will forms and written directions made well in advance of care. What a person wrote down in a living will years ago may bear no relation to the current feelings of a person now facing a health crisis. Patient wishes may have changed. Filling out a living will is an “act of speculation.”

Disingenuous. How is a patient-proxy discussion held years ago any different from written instructions in a living will from that same time? Both may not represent a patient’s current wishes. AWD agrees that Five Wishes and proxy discussions need to be kept current. Many people have no one to serve as a proxy. That is why they leave written instructions for the time when they can’t speak or make decisions. As an aside, this criticism of living wills is odd because almost all detractors of Five Wishes provide their own living wills.

Objection 3: The Five Wishes definition of life support includes artificial nutrition and hydration which is contrary to Church teaching.

Misleading. The new Finishing Life Faithfully guide makes it clear that artificial food and hydration are considered “ordinary care” and in most cases are considered morally obligatory for Catholics. The Five Wishes definition of life support tracks the statutory language of Florida and most states (Florida defines it in Chapter 765 to include “artificially provided sustenance and hydration, which sustains, restores, or supplants a spontaneous vital function.”) This language alignment protects Five Wishes’ legal validity and is common to most state-specific forms. Five Wishes, unlike hospital and attorney forms typically available to patients, invites users “to limit the meaning of life-support treatment because of my religious or personal beliefs” and provides space directly below the definition of life support for this purpose. Many Catholics write, “I want the teachings of the Catholic Church followed on decisions involving life support.”

Objection 4: “Check the box” forms are overly simplistic

Talk about simplistic! Five Wishes is not just a “check the box” form. The content preceding the boxes to be checked is sophisticated yet simple. It was designed by physicians and nurses to be usable in critical care situations, and edited by language experts to be accessible and easy to use. Further, Five Wishes provides space for patients to write in their own additional instructions to ensure compliance with Catholic social teaching. Most advance directives are hard to understand and impractical in health care settings. Five Wishes is popular because its design puts advance care planning within the reach of most people.

Objection 5: “Check-the Box” forms like Five Wishes, POLST and MOLST are not a good way to go.

Mixing apples and oranges. It is misleading  to lump POLST/MOLST forms with Five Wishes. POLST/MOLST are medical orders that must be signed by a doctor. Five Wishes is signed by a patient. Lumping these together because they both have boxes is misleading and confusing.

Objection 6: Including Finishing Life Faithfully as an insert to Five Wishes is “damage control.”

False. Making the teachings of the Church accessible to the faithful should be celebrated, not denigrated. One prominent Catholic advance directive directs users to read 77 USCCB ethical directives and 50 pages of papal writings. In March 2024, at the request of Archbishop Thomas Wenski, the USCCB Committee on Doctrine did a review of both Five Wishes and Finishing Life Faithfully and found nothing to prevent their use by Catholics. Many promnent US Bishops wholeheartedly support the use of Five Wishes and Finishing Life Faithfully by their Catholic parishioners.

Objection 7: There should not be a “For Catholics Only” approach to end-of-life decision- making as promoted by Finishing Life Faithfully.

Hypocritical. Most critics of Finishing Life Faithfully and Five Wishes recommend or actually provide advance directives specifically written for Catholics. Five Wishes is used by people of all faiths or none at all. Finishing Life Faithfully helps Catholics inform their decisions to achieve a dignified end to life.

Objection 8: Five Wishes promotes “radical autonomous choice” which goes against Church teaching.

False. Five Wishes actually limits patient autonomy. It states, “Nothing shall be done or omitted with the intention of ending my life.” Most other advance directives encourage patient autonomy, including Catholic-specific ones. The Church promotes the patient’s exercise of prudential judgment. Five Wishes specifically urges consultations with doctors, family members and clergy so that patient choices are properly informed.

Objection 9: Five Wishes is a “Trojan Horse” for euthanasia and assisted suicide.

False. AWD, the distributor of Five Wishes, was founded in 1996 to oppose assisted suicide. Its Assisted Suicide Watch program is a national resource to educate the public of its dangers. Because Five Wishes addresses comfort, pain management, dignity, and spiritual issues, it provides people with a hopeful vision of end-of-life care while specifically renouncing euthanasia and assisted suicide. Five Wishes, unlike nearly all advance directives which are biased by withdraw/withhold language, allows patients to choose life support.

Objection 10: The Five Wishes treatment of “permanent and severe brain damage” uses broad and imprecise language as if all treatment options are morally equivalent.

False. Five Wishes conditions a patient’s choice in this situation for when a patient is “not expected to get better AND life-support treatment would only delay the moment of [his or her] death,” making clear its narrow application. Five Wishes also permits a patient to allow the doctor to begin life-support and continue it if it helps improve a patient’s “health condition or symptoms.”