Take and Eat

The wrenching story of Terri Schiavo is by now well known. She is 39 years old and has been in a persistent vegetative state (P.V.S.) for 13 years because of brain damage brought on by a heart attack. There has been fierce conflict among her husband, her parents, Governor Jeb Bush of Florida and many others about how to handle her medical situation. There is not even agreement about her prognosis. It is especially heartbreaking, from a spiritual point of view, that she was not permitted to receive Communion during the brief time when she was recently removed from tube feeding.

Ms. Schiavo’s situation is not unique in medical and moral history. Other such cases included Paul Brophy, Claire Conroy, Nancy Cruzan and Hugh Finn. These cases demonstrated legally that removal of life-sustaining medical technology is not murder, but rather a decision to allow a person to die. (See “Hugh Finn’s ‘Right to Die,’” by John Paris, S.J., Am., 10/31/98.) It remains a burning issue for many families today.

What Is a Persistent Vegetative State?

According to the Canadian Medical Association Journal (2/24/98), P.V.S. is an eyes-open state of unconsciousness with sleep-wake cycles, in which patients are completely unaware of themselves or their surroundings. The P.V.S. patient sustains a loss of all higher brain functions, with either complete or partial preservation of brain-stem automatic functions—for example, blinking and smiling.

Recovery of consciousness is highly improbable after 12 months if the P.V.S. condition is caused by traumatic brain injury, or after three months if caused by a nontraumatic brain injury. The patient usually lives from two to five years. Death is normally brought on by an infection in the lungs or urinary tract or respiratory failure, or it occurs because of unknown causes. The length of survival depends in part on how aggressively these types of medical complications are treated.

Catholic Church Teaching

In an allocution he gave in 1957, Pope Pius XII presented a concise formula for approaching medical and moral decisions. He taught that “[n]ormally one is held to use only ordinary means—that is to say, means that do not involve any great burden for oneself or another.... Life, health...are, in fact, subordinated to spiritual ends.” This same point is repeated in the Declaration on Euthanasia, published in 1980 by the Congregation for the Doctrine of the Faith. This declaration suggests, however, that it is better to use the terms proportionate means and disproportionate means of treatment in order to distinguish between what medicine might think of as ordinary or extraordinary and what moral discernment might call proportionate or disproportionate. The medical field now considers dialysis ordinary, for instance, but its use might be judged morally disproportionate in a given case (for example, for a person diagnosed with terminal cancer).

The terms “ordinary” and “extraordinary” were first used in the 16th century to make clear that one is bound to preserve life only throughmedical procedures, means and medicine common to all and helpful to the patient. In 1958 the well-respected moralist Gerald Kelly, S.J., reiterated this tradition by teaching that medical means are proportionate only if they offer a reasonable hope of benefit for the patient and can be used without excessive pain, expense or other inconvenience.

Morally, then, no one is obliged to undergo interventions that are disproportionately burdensome or offer no realistic expectation of restoration of health. While now arcane, an enlightening example can be located in the Relationes Theologicae of Francisco de Vitoria, O.P., a respected 16th-century moralist. Eggs are a common food, he wrote, while chickens and partridges are not. One is obliged to eat only what is common and useful, even if the doctor gives orders to eat partridge to prolong one’s life. In other words, a special diet is not obligatory if it is considered extraordinary or uncommon for the sick person.

We might ask, how does this moral tradition apply today to medically assisted nutrition and hydration? In his 1950 essay in Theological Studies, “The Duty of Using Artificial Means of Preserving Life,” Father Kelly judged that “no remedy is obligatory unless it offers a reasonable hope of checking or curing a disease... [A]rtificial means not only need not but should not be used, once the coma is reasonably diagnosed as terminal. Their use creates expense and nervous strain without conferring any real benefit.” Another highly regarded moralist, Kevin O’Rourke, O.P., recently affirmed the same point of view: “If the cognitive affective potential is nonexistent, the person is still a human being, but a human being toward whom we do not have an ethical obligation to prolong life.”

Critical Guidelines

In 1992 the Committee for Pro-Life Activities of the National Conference of Catholic Bishops issued Nutrition and Hydration: Moral and Pastoral Reflections. The statement affirms that we must preserve human life, while acknowledging that such a duty has limits. It defines euthanasia as an act of commission or omission by an individual whose intent is to cause the death of another person. The bishops stressed, however, that we should not assume that “all or most decisions to withhold or withdraw medically assisted nutrition and hydration are attempts to cause death.”

On the matter of sustenance, the bishops wrote that the teaching of the church “has not resolved the question whether medically assisted nutrition and hydration should always be seen as a form of normal care.” An unconscious patient is still a living human person with inherent dignity and value. But the term vegetative, unfortunately, obscures this critical point, suggesting that the P.V.S. patient is “a subhuman animal.” The bishops’ statement makes clear that the presumption should be in favor of tube feeding “to patients who need it, which presumption would yield in cases where such procedures have no medically reasonable hope of sustaining life or pose excessive risks or burdens.”

Pope John Paul II wrote to the U.S. bishops in L’Osservatore Romano (10/7/98) that tube feeding should be presumed and should be considered an “ordinary means of preserving life.” In his statement, the pope likewise said that careful consideration must be given to all the factors involved—meaning the medical situation of the patient as a whole. A presumption favoring tube feeding is thus normative, but it is not without exception.

The National Conference of Catholic Bishops in 1994 issued Ethical and Religious Directives for Health Care Services. Directive 58 says that nutrition and hydration should be presumed “as long as this is of sufficient benefit to outweigh the burdens involved to the patient.” In following these directives, certain rules apply:

1) Patients who can swallow must receive fluids and food.

2) Assisted nutrition and hydration should not be offered to patients who are clearly in the last stages of dying.

3) Life-sustaining treatment should not be withdrawn from a pregnant woman if continued treatment may benefit her unborn child.

4) Be cautious about assisted nutrition and hydration for patients with end-stage dementia or multiple medical illnesses.

5) Feeding tubes are helpful in situations of transient swallowing problems with a reasonable hope of recovery.

6) The presumption in favor of medically assisted nutrition and hydration is analogous to the use of resuscitation in the setting of a cardiac arrest; it is favored, but there may be situations in which it would make no sense and would be medically contraindicated.

Life of the Spirit

As already mentioned, the teaching of the church maintains that our life and health are in fact subordinated to spiritual ends. The pursuit of spiritual goods is intimately connected with human life. Physical existence affords one the opportunity to love God and others. Human life must always be weighed against the spiritual goods of life and ultimately our final goal of eternal life with God.

P.V.S. patients have reached a point in their lives at which their ability to pursue the spiritual goods of life has been totally eclipsed. They are beyond the reach of medical treatment. They should be provided supportive nursing care and be allowed to die peacefully.

Some will immediately ask, “Would not assisted nutrition and hydration be of benefit to a P.V.S. patient?” The Declaration on Euthanasia teaches that one can determine whether a medical treatment (tube feeding, for example) is proportionate 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.”

The moral question is clear: for the P.V.S. patient, does assisted nutrition and hydration offer any reasonable hope of benefit? Will tube feeding improve the patient’s condition to the point that the sick person is able to pursue the spiritual goods of life?

I think not. While it is true that tube feeding will provide sustenance to prolong life, where is the benefit? It does not restore these patients to a state of relatively good health. Tube feeding prolongs the P.V.S. patient’s life, but this life will never improve to the point where the sick person can pursue the spiritual goods of life.

Some moral theologians take another position, maintaining that tube feeding is always of benefit because it preserves a person’s life and prevents death. This argument, in my view, absolutizes human life and fails to understand that human life isrelative to eternal life with God. Medical treatment has as its primary aim to cure or at least bring a benefit to a patient with a clinically diagnosed condition. Great moral theologians of the 16th and 17th centuries held that even the taking of food could be considered extraordinary or morally optional, depending upon one’s condition and circumstances. These theologians were speaking of taking food in the natural manner. How much more would their comments apply to our modern methods of medically assisted nutrition and hydration?

In cases of P.V.S., a decision to withhold or withdraw medically assisted nutrition and hydration is not the moral equivalent of murder. Rather, as the Texas bishops wrote in On Withdrawing Artificial Nutrition and Hydration (1990), it is an acceptance of the limits of life and a faith-filled affirmation “that the person has come to the end of his or her pilgrimage and should not be impeded from taking the final step.”

There is nothing in the Catholic tradition that morally prohibits one from acknowledging that P.V.S. patients have come to the end of their lives and should not be denied their dying and entering into eternal life with God. Hence this reflection of St. Cyprian, prayed for the patient by family members and friends, can be a source of help and strength as they await transition to life:

When the day of our homecoming puts an end to our exile, frees us from the bonds of the world, and restores us to paradise...we should welcome it. [W]e look upon paradise as our country, and a great crowd of our loved ones awaits us there, a countless throng of parents, brothers and children longs for us to join them.... Let all our longing be to join them as soon as we may. May God see our desire, may Christ see this resolve that springs from faith, for he will give the rewards of his love more abundantly to those who have longed for him more fervently.