The National Catholic Review
On providing food and fluids to helpless patients

In September 2007, the Congregation for the Doctrine of the Faith issued a Response approved by Pope Benedict to answer two questions posed by the U.S. Conference of Catholic Bishops on our moral obligations to patients diagnosed as being in a so-called “persistent vegetative state” (PVS). The Response and accompanying Commentary reaffirm and further explain the teaching offered by Pope John Paul II in an Address of March 20, 2004 on the obligation to provide medically assisted food and fluids to PVS patients when they need such assistance to survive.

Some reactions to the Response have misinterpreted the Response itself, prior Church teaching on the obligation to sustain life, or both. Cases in point are articles published in America by John J. Hardt (Jan. 21) and Thomas A. Shannon (Feb. 18). Essential elements for understanding the Response include the following:

1. The duty to provide basic care

Hardt and Shannon cite the Declaration on Euthanasia of 1980 on the discretion patients may have to refuse medical treatment that seems to them burdensome, and therefore “extraordinary” or disproportionate. They observe that this judgment by a patient is distinct from a physician’s judgment that a treatment is “medically ordinary” in the sense of being customary or usual. This is valid as far as it goes. However, there is an aspect of patient care even more basic than the distinction between ordinary and extraordinary medical treatments: the “ordinary care” owed to sick persons because of their human dignity, which the Declaration said should be provided even when specific treatments or curative efforts are withdrawn as useless or overly burdensome. Pope John Paul II and his successor hold that food and water, even when their provision may require some medical assistance, are aspects of such “basic care” that helpless patients generally should receive. These are not medical treatments judged by whether they cure the patient or improve his or her condition. They are basic necessities of life which often require help from others in the case of those who are very young, very old, or very weak at any age.

Particularly for medically stable patients in a “vegetative state,” who may live a long time with continued nourishment but will die soon of dehydration or starvation without it, this duty of basic care for helpless fellow human beings presents itself in a very direct way. Such a patient’s condition should not be dismissed as “unstable” or terminal simply because one could make it so by choosing to deprive the patient of food and water.

2. Limits to this obligation

Even this obligation to provide basic care reaches its limits in rare cases, when such assistance can no longer fulfill its basic purpose or finality. The U.S. bishops asked whether food and fluids should be provided “except when they cannot be assimilated by the patient’s body or cannot be administered to the patient without causing significant physical discomfort,” and the CDF answered in the affirmative.

These two circumstances—failing to provide effective nourishment, and directly causing significant suffering—can often occur when patients are imminently dying and their bodily systems are shutting down at the end of life. This is why physicians did not initiate tube feeding for Pope John Paul II himself when he was in his final days. No one should think that the Holy Father’s actions were in any way inconsistent with his teaching, or that his condition was comparable to that of a PVS patient who can live a long time with assisted feeding.

Somewhat confusingly, Shannon claims the Response allows three exceptions to the moral obligation and Hardt says it has four. The CDF Commentary does speak of a third situation where the obligation to provide nutrition and hydration does not apply. This is not so much a specific exception but an application of the rule that we are not bound to do the impossible: Some parts of the world may be so destitute or undeveloped that they lack the medical resources and skills for this moral dilemma even to arise. Hardt suggests that the CDF Commentary speaks of yet a fourth exception, a broader and subjective category of “burden” that includes a dislike for survival in a helpless state. But that claim has no foundation in the text, is actually contradicted by the Response, and raises an additional problem that is discussed below.

3. The teaching on euthanasia by omission

Hardt and Shannon acknowledge that a concern about euthanasia is part of the background for the CDF’s Response. However, neither cites the longstanding Church teaching that an omission of basic care may itself be euthanasia. Euthanasia is defined in the Declaration of 1980 as “an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated.” Such euthanasia is always morally wrong.

Here the Church insists on the important distinction between validly withdrawing a life-sustaining means because the means itself is burdensome, and wrongly withdrawing it because (in someone’s view) life itself has become burdensome and should be brought to an end.

To cite this distinction in no way dismisses or minimizes the real suffering of long-term illness, or the real costs and burdens that families may undergo in caring for a helpless family member diagnosed as being in a PVS. In his 2004 Address, John Paul II drew attention to this problem, insisting that such families “cannot be left alone with their heavy human, psychological and financial burden” but must receive assistance from medical professionals, society and the Church. This is the true meaning of “compassion” in the face of illness and disability, to “suffer with” the afflicted and lighten their burden through our support. The solution does not lie in seeking ways to hasten the patient’s death and in that way lift burdens from patient and family.

Hence the CDF Response, answering the second question posed by the USCCB, says that assisted feeding may not be discontinued simply on the grounds that “competent physicians judge with moral certainty that the patient will never recover consciousness.” In other words, some may claim that this kind of state, when prolonged, makes survival itself into a burden; but that does not justify removing food and water so the patient will not survive.

Some ethicists want to assess all the costs and burdens of caring for a helpless patient in a PVS, and then count these among the “burdens” of assisted feeding. One problem this approach raises is the question of intent. By omitting food and fluids, what are we trying to achieve? What “burden” are we trying to ease? The CDF’s critics admit that assisted feeding is often not difficult or costly to provide in itself. They refer instead to the housing, nursing care, and other basic needs of a helpless patient who may never be able to care for himself or herself again. Rather, discontinuing assisted feeding frees us of these burdens only in the sense that it ensures that the patient dies, and hence is in no need of any care. Against this proposal the Church insists that we may not directly intend a patient’s death, as a good in itself or as a means to another end, whether we pursue this end by action or omission.

4. The unity of the living human person

Finally, the claim is sometimes made that the life of a PVS patient—the life that would be ended by withdrawing this patient’s food and fluids—is not a fully human or personal life, but a “baseline biological existence” or merely “physical” life without inherent meaning or value. Such a life is seen as having only instrumental value, so that nutritional support is warranted only if it may restore the patient’s ability to engage in the activities that (in the view of some) make earthly life worthwhile. However, this argument poses a threat to all human beings with mental illness, retardation or cognitive disabilities who are not visibly pursuing such “worthwhile” activity.

It was against this trend that Pope John Paul II, in his 2004 Address, reaffirmed that “the intrinsic value and personal dignity of every human being do not change, no matter what the concrete circumstances of his or her life…. Even our brothers and sisters who find themselves in the clinical condition of a ‘vegetative state’ retain their human dignity in all its fullness. The loving gaze of God the Father continues to fall upon them, acknowledging them as his sons and daughters, especially in need of help.”

Our love and support for patients in PVS should be modeled on God’s love, which is based not on their current ability to act and respond but on their perduring dignity as human beings, made in His image and likeness and facing an ultimate destiny with Him. Earthly life is not the highest of all goods, and our hope in eternal life puts in proper perspective all disproportionate and burdensome efforts to sustain life. However, life is the first and most basic good of the human person, the condition for all others: “Life is always a good” (Evangelium vitae, 34). The way we treat this life here and now—especially the life of those who are most helpless and least able to care for themselves—has consequences for our own eternal destiny.

Persons in the so-called “vegetative state” deserve our unconditional respect. As Pope John Paul noted in his 2004 Address, they should receive all reasonable assistance aimed at their recovery and rehabilitation. But even if such efforts at recovery do not succeed, we need to provide friendship and practical help to their families, and treat these patients always as fellow human beings in need of basic care. In this way our Catholic community can build a culture of life that excludes no one from the circle of love and mutual support.

Cardinal Justin F. Rigali is Archbishop of Philadelphia and Chairman of the Committee on Pro-Life Activities, United States Conference of Catholic Bishops (USCCB). Bishop William E. L

Comments

JULIE WILBERDING DR | 2/2/2010 - 12:37pm
I take exception to the point regarding the concern that mentally ill, cognitively impaired, or retarded live a life that is devoid of fullness. I don't believe that is what the critics imply when they refer to "baseline" condition. If one were to speak of the PVS state in terms of whole brain function vs brain function of someone mentally ill for example, I think you would find quite a big difference. Shannon and Hardt are likely referring to the fact that for the PVS patient, there is no possiblity for human engagement and no possibility for engagement with God. There is no fulfillment on their part. To know and to love God and other is impossible from what medicine tells us of this condition. To equate this condition with mental illenss, mental retardation, or cognitive impairment of some sort is disengenuous at best and alarmingly insenstive and ignorant at worst.
STEVEN DZIDA | 10/22/2008 - 12:47am
Does AMERICA give each of its authors the "courtesy" of reprinting in full and without alteration any article about which the author objects to editorial alterations? Or is this a special dispensation given only to bishops? Perhaps the alterations really were substantive and significant enough to warrant this accommodation. In any event, it is clear that the bishops inspected promptly and carefully the editors' work and did not shrink from immediately registering their objections. I am sure that they were just as vigilant in watching over the conduct of their brother bishops in their continuing mishandling of the ongoing sexual abuse scandal AND just as quick to immediately register publicly their objections to such conduct. Then again, maybe not! Why are our bishops so shocked when the public (especially non-Catholics, but even faithful Catholics as well) gives such little weight to the bishops' prophetic statements about such momentous issues as war and peace, poverty and the economy, abortion and racism? People have observed the bishops essentially giving each other a "pass" on their sinful and scandalous enabling of clerical abusers and conclude that the bishops can say nothing else worth listening to.
Jim CONNIFF FAMILY | 10/21/2008 - 3:32pm
The earlier comments have their own dissenting merit, but that last reduction dovetails with a basic of journalism as I'm not alone in having practiced it for decades. The rule of thumb has always been that both parties have a chance to check edited copy before it runs to make sure it contains "no factual or interpretative errors of omission or commission." It's such a simple insurance policy I'm surprised AMERICA doesn't carry one. Applying it could have save ink, spared legitimately ruffled feathers, and served your readers better. Jim Conniff
GEORGE GARTHOFFNER | 10/17/2008 - 6:05am
After comparing the original of "In Defense of Human Dignity" with the your previously printed revision, I find myself questioning the authorship of any submissions to "America" magazine. Am I reading the opinion of an expert in the subject, or the editorial staff's opinion; and I thought the government was the only institution that lacked credibility. Perhaps in the future you might do the authors the courtesy of submitting "final copy" of their article to them for approval before going to print.
EDMUND KAL MD | 10/11/2008 - 9:30pm
After all the foregoing discussions on this subject, there remains a question that neither his Eminence and Excellency, nor the CDF's Response and Commentary manage to answer. To wit: Of what benefit at all is further nutrition and hydration, especially if administered by any other than strictly natural (i.e. mouthfeeding)means, to the person in a permanent vegetative state? The person, if truly in such a state, can no longer think nor will, can neither sin nor merit for eternal life - in short, can no longer fulfill any of the specifically human actions that give human life on earth its specific goal and dignity: to know, to love, to serve God, and thus merit eternal life with God in heaven (as I learned from 1st grade catechism). Continuing to feed and hydrate a person in this state is tantamount to stoking a fire when there is nothing more to cook or heat or light up, simply to keep the flames going for the memory of it. It may serve to make the caregivers feel virtuous; but for the patient it merely keeps him/her from entering into life eternal, without any further temporal or eternal benefit at all. Unless their eminences and excellencies, and even the CDF itself, have changed their fundamental teachings about the purpose of human life on earth - a supposition that would be preposterous - the only explanation I can think of is that we are talking about different things, when using the term "permanent vegetative state." They seem to equate it, at least qualitatively, with the state of people with various mental disabilities. But I can reassure them, that there is a fundamental difference, qualitatively and not merely quantitatively, between mentally ill or retarded persons and those in a permanent vegetative state. I should know, I've practiced psychiatry for 47 years. They worry that, because of utilitarian or materialistic considerations, too many caregivers will attempt to rid themselves of burdensome patients by declaring them to be in a permanent vegetative state, when in reality they still possess and exercise basic human (i.e. "rational" and not merely "vegetative") functions, albeit in a diminished degree. This is, given our selfish human nature and our more and more this-worldly "Zeitgeist", a legitimate concern. But the reasonable answer to that is to insist that all available scientific means be used to achieve at least moral certitude (defined in an admittedly somewhat circular sounding but classical way as: "that certitude which is sufficient to make a moral decision" in contrast with 100% "absolute" certitude) that the person is indeed truly in a "vegetative" (i.e. no longer able to reason at all) state, and not just impaired in communicating with the rest of us. But to insist, as the CDF response does, that even if it is morally certain that the patient is in a truly vegetative state without any reasonable expectation of eventual recovery, he/she should continue to be fed/hydrated - virtually ad infinitum - is as exaggerated a demand as teaching (as I was in my childhood) that even an unintentionally licked off snowflake while walking to church on Sunday (those were the days without SUV's ...) breaks the at that time still existing long Eucharistic fast, and forbids one from receiving Communion. Ultimately, the basic problem I see with this Response of the CDF, as well as many other recent hierarchical pronouncements (e.g. about politics), that they act like chefs who teach their students dozens of recipes to be implemented with mechanical meticulousness, instead of acquainting them with the basic principles of cooking and encouraging and assisting the students to make up their own recipes according to the specific circumstances in which they happen to find themselves.
Michael Bindner | 10/10/2008 - 8:35pm
His Eminence and His Excellency are still wrong in those cases where life has been restored unnaturally after the patient has experienced natural death and been restored by extraordinary means, such as defibulation and CPR. This is especially true if the patient has been dead longer than four or five minutes and has never regained consciousness. In these cases, installing a feeding tube is an extraordinary measure. Indeed, prolonging resucitation past the point of brain death should itself be outlawed, regardless of the desires of the medical staff or the family. In other words, they are still wrong about Terri Schaivo.