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Pope John Paul II affirms obligation to feed patients in the “vegetative” state

Mar 20, 2004 | Medical Ethics

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.

Categories: Medical Ethics