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From the December, 2004 issue of Touchstone

 

Food & Drink for the Least of These by Kenneth D. Whitehead

Food & Drink for the Least of These

The Pope Speaks Up for Those on Medical Death Row

by Kenneth D. Whitehead

In March 2004, Pope John Paul II declared at an international conference in Rome that the provision of food and water by tube to unconscious patients in the so-called vegetative state is not “extraordinary” medical care that may or may not be given to them, depending on circumstances, but is rather a part of normal and ordinary patient care. Hence, he said, such care must not be withheld from them, even though most of them have little hope of returning to consciousness, much less of actually recovering.

The pope was in no way saying that artificial means must always be used to keep people alive at all costs, as some who fear being helpless and hooked up to tubes and machines may have feared. On the contrary, he was speaking about a specific class of patients, those in what is called (wrongly) a “persistent vegetative state” (PVS), and he judged that these patients, when they are not in the process of dying, must continue to be supplied with basic food and water—assistednutrition and hydration (ANH), as the technical term has it.

Those in a “persistent vegetative state” are able to breathe and are fully alive with functioning organs. They are not conscious, but they are not comatose either, since they go through cycles of being “awake” as well as “asleep.” They are mostly unconscious, however, or at least not fully conscious, and they exhibit minimal or no reactions to stimuli or to their environment generally.

The tendency of contemporary medical practice has been to treat them not as regular patients, but as exceptional patients, in a different category from patients who are convalescing or healing. The result has been the increasing willingness to cause them to die by removing their feeding tubes. And so, not surprisingly, the pope’s statement was almost immediately met with widespread indignation and protests. But what did the pope actually say?

What He Said

John Paul II addressed a conference co-sponsored by the Pontifical Academy for Life and the World Federation of Catholic Medical Associations, with the title “Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas.” The pope’s address came at the end of the conference, after a number of his points had already been made by other speakers, and some of them contested by yet others.

Deploring the idea that a term such as “vegetative” could ever be applied to human beings, the pope was nevertheless obliged to use the term himself, since he recognized that it had come to be so “solidly established.” He insisted that there were “well-documented cases of at least partial recovery” of some of these patients, even after many years.

He criticized those “who cast doubt on the persistence of the ‘human quality’” of such patients. Given the nature and the typical permanence of their condition, many people unhappily have come to judge them not only as “hopeless cases,” but even as less than fully human. Speaking “in opposition to such trends of thought,” he insisted 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. A man, even if seriously ill or disabled in the exercise of his highest functions, is and always will be a man, and he will never become a “vegetable” or an “animal.”

PVS patients “retain their human dignity in all its fullness,” John Paul II insisted. “Medical doctors and health-care personnel, society, and the Church have moral duties toward these persons from which they cannot exempt themselves.” The pope further emphasized the crucial point that:

The sick person in a vegetative state, awaiting recovery or a natural end, still has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.), and to the prevention of complications related to his confinement to bed. He also has the right to appropriate rehabilitative care and to be monitored for clinical signs of eventual recovery.

This remains true even when the food and water in question are supplied artificially through a tube, since the tube is simply another means to assist in the ingestion process, much as a baby bottle is a means to assist an infant unable (as yet) to feed himself.

This was hardly surprising or particularly controversial, though it is noteworthy how strongly John Paul II insisted that PVS patients are to be treated as regular patients. Where he seems to have most disconcerted health-care providers and others (including many Catholic ethicists) and aroused vehement opposition, though, came in what he then went on to say:

I should like particularly to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered in principle ordinary and proportionate, and as such morally obligatory insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering.

Not an Option

What is important to note is that “the administration of food and water, even when provided by artificial means, represents a natural means of preserving life, not a medical act. Its use . . . should be considered in principle ordinary and proportionate, and as such morally obligatory” (emphasis added). The pope does add important qualifying language to the effect that the food and water being administered have to be working properly to serve the patient, but his judgment that providing such food and fluids artificially is not a form of medical treatment as such, is a new and very significant development in Catholic moral teaching.

This particular papal statement, in fact, was immediately treated in a number of quarters as something of a medical and moral earthquake, especially in light of current medical and moral opinion in the United States. For the pope was plainly saying that the supply of food and water by tubes is not to be withdrawn from PVS patients, but, on the contrary, is “morally obligatory.” It is to be considered “normal care.”

The pope was drawing here the only possible logical conclusion from what it would mean, morally, to withdraw nutrition and hydration from PVS patients not otherwise in a terminal condition—as is quite regularly advocated and carried out in health-care facilities in the United States today. For what the pope necessarily concluded from this practice is that “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.”

The pope has made the obvious logical deduction. Since letting people who are not dying starve to death is deliberate killing, and since deliberate killing can never be considered a “medical” option, it follows that continuing to provide PVS patients with food and water is obviously and obligatorily called for.

“No evaluation of costs,” he added, “can outweigh the fundamental good we are trying to protect, that of human life.” Here he rightly dismissed today’s all-too-common calculations of “cost effectiveness” when it becomes a question of possibly abandoning care for those who cannot care for themselves. Much as he has maintained in his judgments concerning capital punishment that modern society has ample means to maintain incarcerated criminals rather than executing them, so here he is presuming that modern society possesses the means to maintain the relatively small number of PVS patients.

He added that the families of PVS patients are also entitled to special societal help and support. But he made it clear that cost is not an issue in deciding the moral issues related to the care of PVS patients.

These patients must, then, be maintained alive as long as they are not in the natural process of dying.

Expected Development

In retrospect it does not seem possible to see how Pope John Paul II could have taken any other position, yet some within the Catholic community assert that he has departed from established Catholic principles. What is this controversy all about, and how did it arise?

The justification such Catholics provide is that supplying food and water artificially to patients unable to feed themselves would amount to employing extraordinary or disproportionate means to prolong life indefinitely, which the Catholic tradition has not required as a moral obligation. They argue that keeping these patients alive artificially provides no benefit to the patients themselves, their families, or society, but, on the contrary, constitutes an enormous burden for all involved.

Common sense would probably rejoin that not being painfully starved to death already constitutes a rather substantial benefit. The idea that there is “no benefit” is fallacious, but in any case, the “benefit” argument does not even apply to patients who are not dying. Nevertheless, an entire school of thought within the Catholic tradition has apparently become increasingly prepared to justify cutting off food and water to PVS patients, regardless.

I know of an archbishop who, when a member of his flock wrote him expressing great anxiety about how the Hugh Finn case was being resolved, wrote back to explain that established Catholic teaching does not require that patients be kept alive when there is no benefit to the patient and his family, and when keeping him on feeding tubes imposes an excessive burden all around, etc., etc.—about how, in short, there is no necessity of “prolonging the dying process.” The only flaw in this earnest archbishop’s account was the fact that Hugh Finn was not dying.

It seems to have been very hard for some theologians and Catholic health-care professionals supposedly working on the basis of established Catholic principles to see that some of the assumptions and practices of contemporary American health care are simply incompatible with the Catholic faith. Some Catholics, particularly some theologians, were confident that there would soon be a “development of doctrine” that would allow for the deliberate cessation of food and fluids to unconscious PVS patients on feeding tubes. Instead, the pope has surprised and disconcerted them with a “development of doctrine” different from the one they expected—one that is consonant with the authentic Catholic tradition of protecting and defending human life at all stages and conditions.

It is worth looking at a couple of the theological critiques of the pope’s position that, in the manner that has become almost customary now, appeared just as soon as the pope had spoken. The first of these critiques was an article entitled “Artificial Nutrition, Hydration: Assessing the Papal Statement,” by Thomas A. Shannon and James J. Walter, which appeared in the April 16 issue of the National Catholic Reporter. The second was a statement issued by the Catholic Health Association.

A Major Reversal?

Shannon and Walter argue with the pope’s claim that giving food and water to PVS patients is not a “medical act,” because their principal objections to his position rely heavily on the well-established principle in Catholic moral theology that extraordinary or disproportionate medical means or treatment can sometimes be refused or forgone when they simply prolong life at burdensome cost with no benefit to the patient. But what the pope was at pains to establish is that providing food and water is not medical treatment as such.

This, for Shannon and Walter, represents “a major reversal of the moral tradition of the Catholic Church in assessing whether a particular medical or other intervention is morally obligatory.” In their view, the pope is the one diverging from the Catholic moral tradition—especially since, up to now, there has been no simple designation of any treatment as a priori “ordinary.” They argue that

whether a medical intervention is morally ordinary has historically been determined by its effect on the patient. To argue that what is medically ordinary as determined by its routine usage by physicians is also morally ordinary equivocates on the term “ordinary,” and misrepresents the core of the medical ethical tradition of the Catholic Church, a tradition in place since at least the 16th century.

But what if providing food and water is not a strictly medical treatment at all, as the pope contends? Shannon and Walter do not really address this question, much less answer it. They seem to think they have made their case by pointing out that John Paul II has diverged from the traditional way of determining whether means are ordinary or extraordinary. If they are to convict the pope of departing from the Catholic tradition, they must move the focus of their argument away from the pope’s main contention that supplying food and water is normal care, and hence morally obligatory.

But in and of itself this does not decide the question. These authors are not fundamentally wrong in reminding us that the Catholic medical-moral tradition has strongly emphasized the benefits to, or the effects upon, the patient, and the patient’s caregivers and family, in making judgments about the use of ordinary or extraordinary medical means of treatment. They are even able to cite the Declaration on Euthanasia, issued by the Congregation for the Doctrine of the Faith in 1980, to establish some of the principles they wish to emphasize. But they are surely missing the point if the pope is nevertheless right that supplying food and water does not constitute medical care as such.

A Mistaken Pope?

By moving the focus of the argument back to the effects and benefits of continuing ANH support to PVS patients, Shannon and Walter aim to show that Pope John Paul II is mistaken in his conclusion that such ANH support is morally obligatory. They argue:

There has been a strong moral argument, grounded in the history of Catholic medical ethics, that the use of feeding tubes for nutrition and hydration can be judged in some circumstances as extraordinary, and thus not morally obligatory. This argument has been based on the view that no intervention in the abstract can be judged either ordinary or extraordinary. . . . In the concrete medical setting, it would be improper to say that there are never any burdens connected to feeding tubes. There are physical burdens and harms that can be associated with artificial nutrition and hydration. The treatments can be expensive, especially the placing of the feeding tube by medical personnel.

They quote the Declaration on Euthanasia’s statement that someone may reject intervention from a desire “not to impose excessive expense on the family or the community.” This, they argue “recognizes that there is no moral obligation to spend either one’s own or the community’s money on treatments that do not bring benefit to patients’ overall condition or that might be judged burdensome or psychologically repulsive.”

Here we reach the heart of their argument (and that of many others today): Interventions that are judged to be too burdensome, and that supposedly bring no apparent benefits, cannot be morally obligatory. Such interventions can surely be forgone or refused, especially when it is considered, as the writers immediately add, that “John Paul II seems to represent to us an elevation of biological or physical life to an almost absolute value” and that “the Catholic medical ethics tradition has not required that a person actually be dying before interventions could be terminated.” As we shall see, this last assertion is not strictly true—and it is certainly not true of what the pope is now authoritatively teaching on the subject.

Where all this leaves us is that, while John Paul II insists that giving PVS patients food and water is morally obligatory, Shannon and Walter, citing principles they have mostly taken from the Catholic tradition of medical-moral analysis, hold that the pope is mistaken and that it is morally possible to remove the feeding tubes that sustain patients in a persistent vegetative state.

If this judgment amounts to a “major reversal” of how the Church has traditionally looked at patient care, namely, from the standpoint of patient or societal benefits, or lack of them, then so be it. We are clearly in a new situation when it has become accepted that some people can be starved to death. Principles of traditional Catholic moral analysis that were developed to deal with patients who were in the process of dying cannot now legitimately be brought forward in this new situation and cited as if they applied to a class of patients who are not dying.

The pope, of course, continues to maintain that some PVS patients, however few, do return to consciousness and even recover. This is true. (What has happened in this connection, by the way, to the very common and widely accepted argument that criminals should never be executed because some of them, if only a very few, may have been wrongly convicted and could therefore be executed “by mistake”? Presumably society must maintain such criminals for the rest of their lives; but meanwhile, is the maintaining of PVS patients who are not naturally dying beyond society’s resources?)

Now a Possibility

John Paul II’s primary objective with his intervention at the Rome conference on PVS patients seems to have been to eliminate as a moral possibility the withdrawal of food and water from such patients who are not dying. Contemporary medical practice, however, has long been tending towards accepting that such withdrawal ought to be standard practice. Unfortunately, some Catholics have apparently been quite prepared to “go with the flow.” The Shannon and Walter article we have just looked at seems to be wholly representative of this way of thinking.

The Catholic Health Association (CHA) has issued its own statement, as if all this history and all these distinctions still applied after the pope has so plainly stated that providing food and water to PVS patients is not disproportionate when dealing with PVS patients who are not dying but are only severely disabled.

Merely to keep bringing up all these points, though, implies that the whole question is still somehow “open.” There must be, the CHA says, “dialogue among sponsors, bishops, and providers. . . . As that dialogue commences, we assume that the guidance contained in the current [US bishops’] Ethical and Religious Directives for Catholic Health Care Services, as interpreted by the diocesan bishop, remains in effect.”

Actually, the current bishops’ Ethical and Religious Directives for Catholic Health Care Services, issued in 2001, already contain a strong “presumption” in favor of providing nutrition and hydration to all patients—with the whole question of “benefit” still built in, however. ANH should be provided “as long as this is of sufficient benefit to outweigh the burdens involved to the patient” (#58).

Similarly, the statements that most state Catholic conferences have made over the past decade or so lean strongly towards the obligatory ANH provision to PVS patients. The exception seems to be a 1990 statement by the Texas bishops that states:

The morally appropriate forgoing or withholding of artificial nutrition and hydration from a permanently unconscious person is not abandoning that person. Rather, it is accepting the fact that the person has come to the end of his or her pilgrimage and should not be impeded from taking the final step.

But the pope’s main point, of course, is that PVS patients who are not actually in the process of dying have not come to the end of their “pilgrimage,” and they should not be hurried down that road by deliberately causing them to be dehydrated or starved to death.

Why Do They Die?

More substantively, the CHA correctly cites the “Papal Allocution” as stating that the PVS patient from whom food and water have been withdrawn “dies of starvation and thirst.” However, it claims that the “Church teaching until now” is that “the person dies of the underlying pathology, i.e., brain injury and the inability to swallow.”

Thus, according to the CHA, the PVS patient does not die as a result of the deliberate dehydration or starvation that has been imposed upon him; rather, he dies of what is euphemistically described as an “underlying pathology . . . the inability to swallow.” This is like saying that a person who is strangled dies from “an inability to breathe.” What is being omitted here, precisely, is the actual cause of the person’s death, the deliberate cutting off of his food and water.

While it is true that PVS patients cannot swallow, they can ingest food and fluids by means of a feeding tube, and the cause of their death, “starvation and thirst,” thus comes about when this tube is removed. It is simply astounding that the CHA could dignify such a sophistry as holding that these patients really die because of an “underlying pathology . . . the inability to swallow.”

The reluctance of many Catholics professionally engaged in the health-care field to make the proper distinctions, and to see which way church teaching has inevitably been tending, is disappointing when we consider other contemporary church teaching documents that have increasingly been making clear that withdrawal from unconscious patients of the various modern means (including ANH) that help sustain life only becomes permissible when the patient is actually dying or when his death is “imminent.”

Thus, the Catechism of the Catholic Church (#2278) recognizes in all the traditional cases of “discontinuing medical procedures which are burdensome, dangerous, extraordinary, or disproportionate,” the right of “refusal of ‘overzealous’ treatment.” However, these things are only possible, the Catechism states, “when one does not will to cause death” (which surely is the case, however, when ANH is deliberately withdrawn) and when one no longer has the ability to “impede” death.

In 1985, the Pontifical Academy of Sciences stated in “On the Artificial Prolongation of Life” that “if a patient is in a permanent coma, irreversible as far as possible to predict, treatment is not required, but all care should be lavished upon him, including feeding” (emphasis added). Here a distinction is clearly made between medical “treatment” and the provision of “nutrition.” The pope did not arbitrarily pick this distinction out of the air.

Similarly, in his 1995 encyclical Evangelium Vitae (“The Gospel of Life”), Pope John Paul II said that only in situations “when death is clearly imminent and inevitable, one can in conscience ‘refuse forms of treatment that would secure a precarious and burdensome prolongation of life, so long as the normal care due the sick person in similar cases is not interrupted.’”

Again, in a Charter for Health Care Workers issued by the Pontifical Council for Pastoral Assistance to Health Care Workers in 1989, it is stated that “when inevitable death is imminent, despite the means used, it is licit in conscience to decide to refuse treatment that would only secure a precarious and painful prolongation of life.”

A Clear Teaching

It is not surprising that Catholic doctrinal development has made it more and more clear that those extraordinary or disproportionate means that can be renounced in specific circumstances were, in fact, accepted by Catholic moral theology only for patients who were either already dying, or else were afflicted with diseases that would soon prove fatal to them. They were assuredly not to be applied to patients who were not dying.

All of the traditional Catholic principles and safeguards against overzealous or useless medical treatment remain in place, in strict accordance with traditional Catholic teaching. But there is now also another clear teaching on the record, thanks to Pope John Paul II: that PVS patients who are not in the process of dying should not be deprived of food and fluids in order to bring about their deaths.

We should be thankful that the pope has seen fit to speak so decisively on this matter at this time, when yet another group of vulnerable and defenseless people are in danger of losing their lives.

Legal Starvation

Numerous cases of patients in permanent vegetative states have made headlines in the United States: the Hugh Finn case in Virginia several years ago and the Terri Schiavo case in Florida, for example.

These cases came to public attention because some family members opposed the efforts of other family members to have the patient’s feeding tubes removed, thus precipitating public fights in the courts. Where family members agree to discontinue tube feeding, though, it is done without fuss or publicity. This has occurred in many cases in the United States in recent years, especially where “living wills” allow or call for discontinuing such support.

Since the Nancy Cruzan case ( Cruzan v. Director, decided by the Supreme Court in 1990), feeding tubes can be legally withdrawn if the patient or his surrogate has clearly consented to the withdrawal through a living will or by some other verifiable means. A majority of justices concluded that there is a constitutional right to reject artificially provided food and fluids.

The court did permit, however, that in the case of an incompetent patient, a state could require clear and convincing evidence that such a rejection conformed to the patient’s wishes when competent—hence the importance given to real or supposed previous statements of people saying that they would never want to be on artificial “life support.”

Who would? But there are principles involved, and consequences that follow from acting on those principles. Christians have to take all these things into account; it can in no way be just a matter of a person’s wishes, as American law has for now essentially decided.

What it all adds up to is that, in the United States today, it is strictly legal, with “consent,” to starve people to death. The much-publicized court fights where family members of a patient have attempted to stop the withdrawal of ANH (assisted nutrition and hydration) have all revolved around the question of whether the “consent” of a PVS patient was verifiable or proper.

In Terri Schiavo’s case, only in 1998 did her husband begin testifying that she had once told him that she would never want to be kept alive artificially. This was eight years after she had been reduced to a PVS state by an accident—and after her husband had already received and spent on himself considerable insurance money that was supposed to be used for her care and rehabilitation. The only basis on which a Florida court ordered her feeding tube removed was his testimony, though others who knew her disputed it.

This is the context in which Pope John Paul II has now judged that PVS patients not in a terminal condition may not be denied food and water. In assessing the meaning and importance of the pope’s teaching, we must never lose sight of the situation he was addressing: that it has become a common, if not preferred, medical judgment that ANH serves no positive purpose for PVS patients or for society and should therefore not be given.

The patients should simply be allowed to die “naturally,” as many euphemistically put it. What is generally not stated, though, is that these patients are not dying. Saying that they should simply be “allowed” to die comes to mean , therefore, that they should be dehydrated or starved to death.

So what the pope is saying in the present situation is: No, the Church cannot and does not accept that even “hopeless” PVS patients should be deprived of their sustenance and thereby die of thirst or starvation. To deprive these patients of food and water is equivalent to euthanasia, which is to say, to murder.

The pope is also looking at the consequences of agreeing that keeping PVS patients alive constitutes an extraordinary or disproportionate effort, and one that is therefore not morally obligatory. If this were accepted, what would be the next category of patients to be disposed of? Alzheimer’s patients? Deformed infants?

People sometimes imagine that we can draw moral lines wherever we want to, that is, that we can confine the categories of permitted killings to a given class of patients such as PVS patients. These people are wrong, as the legalization of abortion has long since proved. Once we have decided that we can do away with one class of difficult cases, whose life supposedly poses too great a burden upon themselves or others, nothing will prevent us from moving on to the elimination of the next class of difficult cases. This is not only just likely; it is inevitable.

—Kenneth D. Whitehead

For the text of the pope’s address and other papers from the conference, see Origins, published by the Catholic News Services Documentary Service (April 8, 2004), or www.originsonline.com.


Kenneth D. Whitehead is the 2004 recipient of the Blessed Frederic Ozanam Award for Catholic Social Action of the Society of Catholic Social Scientists (SCSS). He writes frequently on Catholic social and moral issues.

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