At a recent international congress in Rome on “Life-Sustaining Treatments and the Vegetative State,” Pope John Paul II ignited a controversy that is still smoking. He stated that artificial nutrition and hydration “should be considered, in principle, ordinary and proportionate, and as such, morally obligatory” (emphasis his).
At the time, I was called by the religion and ethics editor of USA Today to comment on what seemed to “sweep away the benefits/burdens approach to feeding-tube decisions for Catholic hospitals.” Having only a copy of the Italian text, I said that we needed more time to understand just what the pope was saying. But others weighed in, calling it an end to the debate, a total reversal of the church’s position and, in the words of an ethicist quoted on MSNBC, a proclamation that “feeding tubes should never be withdrawn from any patient care.”
None of these last three statements are true. This has been made quite clear in a number of editorials and articles in newspapers and magazines that have confronted the issue, the most thoughtful and balanced of them being “Must We Preserve Life?” by Ronald Hamel and Michael Panicola (Am., 4/19).
Yet problems and questions persist. I still get inquiries from lawyers, hospitals, health care givers and concerned Catholics wondering what it all means. And there is the abiding danger that misinterpretations may lead to yet more profound crises in health care and the growing obsession with American high-tech medicine. In this context, without any thought of improving on the Hamel-Panicola analysis, I think there are some important observations to be made about this controversy.
1) The context. The papal speech came the day after a heated argument between two physicians from Holland. After one doctor reported rather low rates of euthanasia in the Netherlands, his interlocutor complained that the statistics did not include the withdrawal of nutrition and hydration, a measure he characterized as homicide. The context is crucial here, not only because of Holland’s tolerance of direct euthanasia, but because the withdrawal of food and drink appears, at least to some, as the default position when dealing with unpromising cases.
2) The pope’s driving concerns. There is no doubt, when one reads his whole speech, that John Paul II is unalterably opposed to the intentional killing of human beings, even those described as being in a vegetative state. Moreover, at no time over the span of a human’s life does he or she become a “vegetable.” A human is always a person, no matter what the stage of development or final diminishment.
3) A signal distinction. The pope’s speech, like the entire conference, addresses only the issue of vegetative state. It does not apply, for example, to patients suffering from end-stage cancer, many of whom cannot or will not eat as they are approaching death. There is no suggestion that they must be force-fed to prolong their dying.
4) The subtext. An underlying point of contention (one that will become more pressing in the coming years) is the moral status and the status as humans of persons who appear to have no “higher” brain function. The pope’s position is that a human person is a “kind” of being, not a set of activities or performances. Nor is the person reducible to the higher cognitive faculties. In fact, a human can be a personal kind of being prior to the formation of the brain as well as after the brain is profoundly damaged. Some commentators have called this position “vitalism.” That is correct only to the extent that such “vitalism” identifies the human person with the living (vital) organism and not its cognitive skills. It is incorrect, however, to think that this vitalism makes biological life an absolute value. The pope’s position does not hold that we must preserve our lives at any cost. It holds only that we must never intentionally kill ourselves or others.
5) The focus of the present reaction. The intention to cause death by withdrawal of food and drink invariably leads to death by starvation or dehydration unless an intervening cause of death occurs. But surely the pope cannot mean that the removal of artificial nutrition and hydration in itself causes death. That is contradicted by the thousands of cases where the artificial means (the tube) is removed, but feeding by hand is successfully done. It is the intention to cause the death that is the problem. This will be debated case by case, but one may hope for a full discussion of the meaning of “feeding” and the process of dying—topics insufficiently developed in our present discourse.
6) The neglected focus. I find it strange that the most challenging part of the pope’s speech has been utterly ignored. His whole argument rests upon what he himself calls a universal “right to food, water, health care and therapy.” If the sick person has a right to nutrition and hydration, does not every person have that right? If the profoundly damaged have a right to therapy, do not all of us, rich or poor? So far we have ignored this call for universal health care based on universal human rights. The pope’s talk is as much a challenge to our health care system and the inequities in the world as it is to our treatment of patients. Why can we not see that?
Perhaps the answer lies in the strange phenomenon that a small percentage of the world’s privileged can worry whether they must use every technology to feed themselves while millions do not even have bread and clean water.
