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Pope John Paul II affirms obligation to feed patients
in the “vegetative” state
By Richard Doerflinger
On March 20, speaking to participants in an international congress on the
“vegetative” state, Pope John Paul II profoundly changed the worldwide
debate on how to respond to this condition. He issued the first clear and
explicit papal statement on the obligation to provide food and water for
patients in a “persistent vegetative state” (PVS).
With the Pope’s statement, the Church’s teaching authority has rejected each
aspect of the theory that opposes assisted feeding for patients in a PVS.
The Pope’s speech marks a new chapter in the Catholic contribution to
efforts against euthanasia by omission
For many years, and through many battles in courts and legislatures,
pro-life groups have tried to ensure that these patients receive the food
and fluids they need to survive. (Patients in the “vegetative” state have
sleep/wake cycles and so are not comatose, but by definition they show no
sign that they are aware of themselves or their surroundings.)
Leading the other side of the debate, of course, have been “right-to-die”
groups who see such patients as better off dead (or sometimes see their
families as better off if the patients are dead). Bioethicist Daniel
Callahan warned in the Hastings Center Report in October 1983 that many of
his colleagues favored broad policies for withdrawing feeding tubes not
because of special burdens involved in such feeding, but because “a denial
of nutrition may in the long run become the only effective way to make
certain that a large number of biologically tenacious patients actually
die.”
With the U.S. Supreme Court’s unanimous rejection of a constitutional
“right” to assisted suicide in 1997, and the refusal of any state except
Oregon to legalize that practice, the euthanasia debate has focused even
more squarely on the removal of food and fluids.
That debate has become a painful and complicated one for several reasons.
One is the intense involvement of family members on both sides of the
ideological discussion – often with members of the same family taking
opposite sides. Another is confusion about the “vegetative state” itself,
which is less a well-defined condition than a set of symptoms in search of
an explanation.
But for Catholics, the most painful complication has been the lack of clear
and unambiguous guidance at the level of Church teaching. The Catholic
Church has long had a complex and nuanced moral tradition on life-sustaining
treatment.
Catholic teaching opposes all intentional killing of patients, even when
that is carried out not by overt action but by omitting basic means of
survival (euthanasia by omission). But this teaching also holds that
patients may validly refuse “extraordinary” or “disproportionate” means for
sustaining life --and it warns against a “therapeutic obstinacy” that may
only impose undue suffering and other burdens on dying patients in an effort
to keep them alive as long as possible. For Catholic theologians, then, the
question has been: On which side of this divide does medically assisted
feeding for the PVS patient fall?
Some Catholic documents have argued strongly that these patients should
generally receive food and fluids, even if this may require medical
assistance. In 1992, for example, the U.S. bishops’ Committee for Pro-Life
Activities issued a resource paper titled “Nutrition and Hydration: Moral
and Pastoral Reflections,” which recommended a strong presumption in favor
of assisted feeding for patients in a PVS.
The paper strongly opposed any removal of these means designed to hasten the
patient’s death from dehydration or starvation; and it found that assisted
feeding is generally not “extraordinary means” – rather it is usually an
effective way to sustain life that does not impose grave burdens on
patients. Similarly, a 1995 “Charter for Health Care Workers” issued by the
Pontifical Council for Pastoral Assistance to Health Care Workers stated:
“The administration of food and liquids, even artificially, is part of the
normal treatment always due to the patient when this is not burdensome for
him: their undue suspension could be real and properly so-called
euthanasia.”
However, a very different approach had also emerged in Catholic theological
circles. That theory held that PVS is best seen as a “terminal” illness, in
which the patient is dying naturally of his or her underlying condition
(which includes a partial or complete inability to swallow food the ordinary
way). Intervening to stop this natural dying process requires special
justification, such as the prospect of reversing the condition, the argument
went.
By this account, simply sustaining life in a state of unawareness is not
beneficial, because it maintains only a “biological existence” that cannot
pursue the higher “spiritual purposes” to which earthly life is directed.
Once a vegetative state is diagnosed as “persistent” and therefore unlikely
to change, says this theory, there should be a presumption against assisted
feeding. The ensuing death by dehydration is not euthanasia but only a
natural death, resulting from the patient’s inability to take food normally.
Even documents which found it argument unconvincing, like the U.S. bishops’
1992 paper, had to admit that it had not explicitly been rejected by the
Church’s highest teaching authority.
As of March 20 this is no longer the case. In his speech the Holy Father
rejected each aspect of the theory that opposes assisted feeding for
patients in a PVS. He said:
1. No living human being ever descends to the status of a “vegetable” or an
animal. “Even our brothers and sisters who find themselves in the clinical
condition of a ‘vegetative state’ retain their human dignity in all its
fullness,” he said. “The loving gaze of God the Father continues to fall
upon them, acknowledging them as his sons and daughters, especially in need
of help.” Against a “quality of life” ethic that makes discriminatory
judgments about the worthiness of different people’s lives, the Church
insists that “the value of a man’s life cannot be made subordinate to any
judgment of its quality expressed by other men.”
2. Because this life has inherent dignity, regardless of its visible
“quality,” it calls out to us for the normal care owed to all helpless
patients – and in principle, food and fluids (even if medically assisted)
are part of that normal care. Such feeding is “a natural means of preserving
life, not a medical act” –-meaning, among other things, that the key
question is simply whether this means effectively provides nourishment and
preserves life, not whether it can reverse the illness.
3. This judgment does not change when the “vegetative” state is diagnosed as
“persistent” or unlikely to change: “The evaluation of probabilities,
founded on waning hopes for recovery when the vegetative state is prolonged
beyond a year, cannot ethically justify the cessation or interruption of
minimal care for the patient, including nutrition and hydration.”
4. Deliberate removal of such means to produce a premature death can indeed
be euthanasia, that is, unjust killing. “Death by starvation or dehydration
is, in fact, the only possible outcome as a result of their withdrawal. In
this sense it ends up becoming, if done knowingly and willingly, true and
proper euthanasia by omission.”
5. In accord with the traditional teaching against imposing undue burdens on
patients, the obligation to provide assisted feeding lasts only as long as
such feeding meets its goals of providing nourishment and alleviating
suffering. But as a counter-balance to arguments for withdrawing such
feeding as burdensome, “it is not possible to rule out a priori that the
withdrawal of nutrition and hydration, as reported by authoritative studies,
is the source of considerable suffering for the sick person.”
This last statement emphasizes another aspect of the Pope’s address: He
showed a thorough familiarity with the latest medical and scientific
findings on the “vegetative state,” which were highlighted by medical
experts during the previous three days of the international congress.
Though co-sponsored by the Pontifical Academy for Life and the International
Federation of Catholic Medical Associations, that congress featured
presentations by world-renowned medical experts of various religious and
moral views, including some who clearly did not agree with Catholic moral
teaching. Yet the dominant medical consensus among these experts was that we
know less about the “vegetative state” than we did twenty years ago – or
rather, we know that our old certainties were premature.
There is no clear agreement on what this state is; on how it can reliably be
distinguished from other states such as certain forms of “locked-in
syndrome” (where patients are aware but cannot communicate with others); on
how long such a state must last before it can be judged permanent; or on how
much brain activity or even perception of stimuli may occur in patients
diagnosed as being in the “vegetative” state.
These new findings clearly made it even easier for the Pope to insist that
in such matters of life and death, we must give these patients the benefit
of any doubt. As he pointed out, “the moral principle is well known,
according to which even the simple doubt of being in the presence of a
living person already imposes the obligation of full respect and of
abstaining from any act that aims at anticipating the person's death.”
Finally, the Pope devoted the closing section of his address to the needs of
families caring for a loved one in a “vegetative” state. The rest of us must
not abandon these families, he said, but must reach out to give them every
possible assistance so they will not face their burdens alone. Respite care,
financial support, the sympathetic cooperation of medical professionals and
volunteers, and psychological and spiritual comfort were among the kinds of
help he urged society to provide.
The Pope’s March 20 address does not answer all questions about extreme
circumstances, nor does it specifically address all questions about handling
“advance directives,” or the conflicts that may arise between doctors and
families when one party proposes a course of action the other finds morally
objectionable.
But he could not be clearer on the main point at issue: When it comes to
providing basic means to nourish the most helpless of patients--including
those who cannot visibly respond to our care--the Catholic Church is on the
side of life.
Richard Doerflinger is Deputy Director of the Secretariat for Pro-Life
Activities, U.S. Conference of Catholic Bishops
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