Clear enough? CDF on withdrawing nutrition & hydration
At the risk of setting off another round of comments on the role of the CDF, have we discussed their recent document on withdrawing nutrition and hydration from PVS patients? If so, I missed it. I believe that this teaching is a regrettable shift in the tradition on end of life care. Among other problems, pastorally, it’s a nightmare.
RESPONSES TO CERTAIN QUESTIONS OF THE UNITED STATES CONFERENCE OF CATHOLIC BISHOPS CONCERNING ARTIFICIAL NUTRITION AND HYDRATION
First question: Is the administration of food and water (whether by natural or artificial means) to a patient in a “vegetative state” morally obligatory except when they cannot be assimilated by the patient’s body or cannot be administered to the patient without causing significant physical discomfort?
Response: Yes. The administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life. It is therefore obligatory to the extent to which, and for as long as, it is shown to accomplish its proper finality, which is the hydration and nourishment of the patient. In this way suffering and death by starvation and dehydration are prevented.
Second question: When nutrition and hydration are being supplied by artificial means to a patient in a “permanent vegetative state”, may they be discontinued when competent physicians judge with moral certainty that the patient will never recover consciousness?
Response: No. A patient in a “permanent vegetative state” is a person with fundamental human dignity and must, therefore, receive ordinary and proportionate care which includes, in principle, the administration of water and food even by artificial means.
The Supreme Pontiff Benedict XVI, at the Audience granted to the undersigned Cardinal Prefect of the Congregation for the Doctrine of the Faith, approved these Responses, adopted in the Ordinary Session of the Congregation, and ordered their publication.
Rome, from the Offices of the Congregation for the Doctrine of the Faith, August 1, 2007.
William Cardinal Levada
Prefect
< < First question: Is the administration of food and water (whether by natural or artificial means) to a patient in a “vegetative state” morally obligatory except when they cannot be assimilated by the patient’s body or cannot be administered to the patient without causing significant physical discomfort?
Response: Yes. The administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life. It is therefore obligatory to the extent to which, and for as long as, it is shown to accomplish its proper finality, which is the hydration and nourishment of the patient. In this way suffering and death by starvation and dehydration are prevented.
>>
Does this represent a shift in traditional church teaching? (I’m asking sincerely, not argumentatively). I don’t claim expertise in this area, but my amateur analysis is that, as the question is framed, there is no mention of a terminal illness, but simply of a vegetative state. I suppose it may be persistent or transitory; and the patient may be terminally ill or not. The question also seems to address the traditional cost-benefit consideration for ordinary vs extraordinary treatment by excluding situations in which supplying the nutrition and water would be ineffective or painful.
Doesn’t it go without saying that, for a patient who isn’t dying and is able to digest food and water without pain, we should supply them with food and water?
Perhaps someone could untangle the issues here.
I honestly have no idea what the nightmare scenarios would be. On the other hand, I do hope that if I’m ever in a situation like this, I will receive food and water.
(I don’t really understand these moral questions.)
Why is it pastorally a nightmare. Is it because it is not explained to people the dignity of those even in these situations where a false compassion reigns where killing them by starving or dehydrating themselves to death?
If it is a pastoral problem it is because too many have taken the wrong way on this issue and have confused people. The idea that removing food and water is disproportionate in the majority of situations is quite evil.
Statement: If I were in a persistent vegetative state with no realistic reason to believe that this state would ever change, then, YES, I would want all forms of life support removed. I would want to be ALLOWED to die. I mention this with emphasis only because the above posts suggests that this is an oddball kind of conclusion to reach.
Questions: Do end of life directives matter in this regard? Is it proper for me to insist that no feeding or hydration be given, just as I can insist that no effort be made to resuscitate me? Can I direct that such food or hydration be given in the short term, to see what happens, but removed in the longer term if nothing but vegetative state seems likely? Would allowing one to reject all such feeding and hydration, but not allowing for the removal of such things after they have begun lead people to reject them outright when they might otherwise do some good?
I think these might be a few of the questions about which Paul and others might have some concerns.
Regarding a change in directive, it has been my understanding that medical interventions may be withdrawn if there is no reasonable belief that the intervention will be effecacious. In this case, one could argue that the feeding and hydrating is doing its job on the BODY, but not doing its job with respect to the health of the PERSON. Yes, one should not entirely separate these two (although I would likely separate them more than most), but such a separation seems to be exactly what has taken place when one only asks about the effecacy of an intervention in terms of its effect on the body.
As a neophyte on this subject, I vaguely recall what may be two problems with this CDF statement:
a. It *presumes* (perhaps wrongly?) that the body of a PVS patient is not already dying, and
b. It *presumes* (again wrongly?) that someone in a PVS is “suffering.”
The CDF also ignores input of “competent physicians [read: "board certified specialists"]” who have determined “with moral certainty that the patient will never recover consciousness.”
There are so many variables in this area that, if I were the pope, I would be reluctant to prescribe a “one size fits all” approach to dealing with PVS patients.
I’m reminded of comments many years ago by a Catholic moral theologian (McCormick?) who asked us to envision a Catholic [storage] facility populated exclusively by PVS/similar patients on ANH. In this scenario, might one be tempted to ask, “Don’t the folks running this place believe in life after death?!?!?”
At the risk of showing my contempt for the CDF, it seems to be giving us a black-and-white solution to inherently complex medical situations, the handling of which might best be determined by specialists on site.
Joe, thank you for distinguishing between the BODY and the PERSON. If I may append, we should also differentiate between EXISTENCE and LIFE.
Again, the CDF offers a simplistic approach to extremely complex situations.
Benedict, please, just go away — and take the CDF with you.
Really!
As much as I hated the right-wing feeding frenzy of Terry Schiavo, and as much as I am disturbed by concern for one woman who is dying while not giving two hoots about Iraqi civilians…. I am still inclined to accept this statement. Here’s why: it fits with an increasing emphasis on the intrinsic worth and human dignity of every person. The Church has moved squarely against the death penalty, favors war in only the strictest of circumstances, and defined torture to be intrinsically evil. It makes sense, from this perspective, to shift the boundaries of the 400-year old ordinary-extraordinary distinction.
But there are still grey areas. This statement merely codifies something John Paul stated in a 2004 allocution. Daniel Sulmasy raised some interesting issues about this (http://www.americancatholic.org/Messenger/Jan2006/Feature1.asp#F3):
“The words ‘in principle’ do not mean ‘absolute’ in the sense of ‘exceptionless’ but allow consideration of other duties that might apply. Therefore, what the papal statement really means is that, for permanently unresponsive patients who are not otherwise dying, tube feeding should be presumed to be ordinary and proportionate (and as such, morally obligatory) unless its use would conflict with other grave responsibilities or would be overly burdensome, costly or otherwise complicated.” (The complete text of this statement has been published in the National Catholic Bioethics Quarterly 4 [2004], pp. 773-82.) ”
I wrestled with this issue a while ago on Vox Nova, and I still haven’t fully resolved it to my own satisfaction (http://vox-nova.com/2007/07/24/when-is-euthanasia-not-euthanasia/)
I would suggest that people read the CDF commentary linked here, before they start having a hissy fit.
http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_20070801_nota-commento_en.html
While it is clear that the CDF now opposes withdrawal of artificial nutrition and hydration in principle, it is also clear that it is not an exceptionless norm — that there are some extreme cases where the norm doesn’t apply. However, the mere fact that a person is in PVS for an indefinite period is not in itself a sufficient reason to withdraw food and water tubes. As someone who was turned off by all of the noise and hysteria over the Terri Schiavo case, the reasoning seems sound. As far as she’s concern, it seems to me that it vindicates her parent’s and brother’s moral position.
Below is taken from an article in the April 5, 2005 issue of the NCR. It is by Edward Sunshine of Barry University in Florida. It may shed light on the question as to whether the current CDF statement represents a change in the Church’s teaching on this matter:
Pope John Paul II’s 1980 “Declaration on Euthanasia” is the standard Catholic reference on end-of-life issues. In section IV, it presents this set of principles: 1) It is for the consciences of sick persons or those qualified to speak in their name to make these decisions. 2) There is a duty to care for one’s own health or to seek care from others. 3) Those who care for the sick should use remedies that seem necessary or useful. 4) The principle that one is never obliged to use “extraordinary” or “disproportionate” means to preserve life still holds good. 5) “In any case, it will be possible to make a correct judgment as to the means 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.” 6) It is wrong to “impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome.”
Clarification is necessary here to avoid needless confusion. First of all, to say that it is for the conscience of sick persons (or their proxies) to decide means that conscience is the ultimate subjective norm of morality in those particular cases. That is standard Catholic moral teaching. When the bishops and the pope teach, however, they discuss objective norms of morality that apply in general. They do not (indeed, cannot) tell people how to act in conscience because conscience is the domain of the person before God. Second, the distinction between “extraordinary” and “ordinary” means is a moral, not a medical, distinction. This means that ill persons, not doctors, determine what constitutes “extraordinary” and “ordinary” means, and that they do this according to an assessment of the burdens and benefits involved, not in line with the criteria of normal medical practice. It is here that differences in moral judgment often arise.
Thanks to Patrick Rothwell for the link above. The following from the commentary is worth looking at:
I agree with Morning’s Minion that the responses to the bishop’s questions are of a piece with the Church’s position on the sanctity of life.
What I find troubling are the questions of the bishops themselves, which seem very narrow and legalistic. I’m not sure, after reading the commentary, that these questions have not really already been addressed by the catechism.
Gerald: You, perhaps quite deliberately, do not indicate how you think this 1980 document compares with the 2004 allocution, or with the just released statement. I see large differences, especially regarding whether feeding and hydration are duties “in principle.”
Here is a real question, one obviously related to this issue: Is it morally improper for Catholic health care professionals to “pull the plug” at the request of the family of someone for whom they are caring? Does the physician just let the family do it? In the current case, would Catholic health care workers have to withdraw entirely from the care of a person if a choice has been made by others to withdraw feeding and hydration, yet matters such as pain relief and care before death still call for the attention of health care professionals, some of whom are obviously going to be Catholic?
Finally, regarding principles. Some wag once said that “Sometimes you just have to forget about your principles and do the right thing.” I think a case can be made that our minds and hearts are sufficiently fallible that pushing principles to their logical conclusion would lead to a misunderstanding of what God demands of us. Clearly our schools have gone this route with their “zero tolerance” policies. Can religious institutions also lose their way by this means? Is this one of the reasons why a robust understanding of conscience is called for?
To better understand the CDF document, and the commentary linked by Patrick Rothwell, it would likely do most of us good (including me) to have a better understanding of the doctrinal development in the Church of the distinction between ordinary and extraordinary means for preserving life. As Morning’s Minion notes, the underlying doctrine is centuries old.
There is an April 2004 article in America, by Ronald Hamel and Michael Panicola, that IMO does a good job of tracing the doctrinal development. The article can be accessed at
http://64.233.169.104/search?q=cache:ygkActoAqf8J:www.america-magazine.org/gettext.cfm%3FarticleTypeID%3D1%26textID%3D3553%26issueID%3D482+hamel+%2B+panicola&hl=en&ct=clnk&cd=5&gl=us
Paul Lauritzen also had a thought-provoking article in Commonweal in March of 2006 on the Church’s shift in the ordinary/extraordinary distinction. The article can be accessed at
http://www.commonwealmagazine.org/article.php3?id_article=1549&var_recherche=schiavo
If I recall, the withdrawal of ANH from Terri Schiavo merely allowed the continuation of the bodily shutdown process that had been interrupted and then stalled for 14 or so years. The autopsy, if I’m not mistaken, confirmed what board certified specialists had determined to be the case all along, namely, that Schiavo didn’t have a snowball’s chance in hell of pulling out of PVS. If this sketchy outline is essentially correct, then one cannot rightly conclude that the actual facts somehow “vindicate[d]” the moral position of Schiavo’s family.
At what point, using the best medical information available over a *reasonable* period of time for examination and evaluation, must the responsible party(ies) conclude it’s time to let God take command of the dying process?
At some point, it is time to “let go and let God.”
From the CDF’s commentary, here quoting JPII’s 2004 address:
“3) “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 possible recovery. 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.”
It seems that we should think of nutrition and hydration, not as a medical treatment like chemotherapy or radiation therapy, but as a basic human right, outside of (and presumably prior to) moral decision-making regarding medical treatment.
In short, food and water fall into a different category.
Jim,
Is there a good reason not to add air to those things that fall into a different category? Should we use machines that not only give air, but also those that enable the lungs to breath, or even which bypass the lungs altogether so as to oxygenate the blood? Are the lungs analogous to a mouth which no longer works but can be bypassed with a tube, such that we can bypass the lungs and provide oxygen directly to the bloodstream?
Hi, Joe, you write:
< < Statement: If I were in a persistent vegetative state with no realistic reason to believe that this state would ever change, then, YES, I would want all forms of life support removed. I would want to be ALLOWED to die. I mention this with emphasis only because the above posts suggests that this is an oddball kind of conclusion to reach. >>
FWIW, I don’t think it’s an oddball kind of conclusion, in the sense that presumably many people would agree with you.
I would ask you, though: would you still make that choice if the choice resulted in excruciating pain and unimaginable suffering? Pain and suffering that could be avoided by the simple expedient of keeping the feeding and hydration tubes in place and, as it were, allowing you to continue to live?
< < Questions: Do end of life directives matter in this regard? >>
Of course they matter very much to the patient, the family, the health care providers and the civil authorities. But it seems to me that there is nothing about an end of life directive that removes the burden of engaging in informed moral reasoning. Quite the contrary: it would seem to me that I have an ethical obligation to see to it that any end of life directive I issue would take relevant church teaching into account. An end of life directive could be in line with, or not in line with, Catholic moral teaching (or any other system of moral teaching).
< < Regarding a change in directive, it has been my understanding that medical interventions may be withdrawn if there is no reasonable belief that the intervention will be effecacious. In this case, one could argue that the feeding and hydrating is doing its job on the BODY, but not doing its job with respect to the health of the PERSON. Yes, one should not entirely separate these two (although I would likely separate them more than most), but such a separation seems to be exactly what has taken place when one only asks about the effecacy of an intervention in terms of its effect on the body.>>
As I pointed out in a separate post, it seems that the Church is not categorizing food and water, even artificially administered, as a medical intervention.
Thinking of the body as somehow separate or distinct from the person makes me nervous. The line of reasoning would seem to open the door to withholding food and water from other persons who have functional deficits, e.g. persons with very low IQs.
Any health care providers (doctors/nurses) here?
One thing I believe would be somewhat difficult to ascertain is this (from the commentary to the questions): “… in some rare cases, artificial nourishment and hydration may be excessively burdensome for the patient or may cause significant physical discomfort.”
If someone is in a persistent vegetative state and cannot respond to pain stimulus, how do we know whether something like a feeding tube is causing pain?
My mother-in-law was unable to communicate in any way after a botched medical procedure and stroke. The doctors told us she could feel and hear, though they were not sure how much she could understand.
The decision was made to take her off the respirator and the feeding tube was removed, though the IV was left in for hydration and to deliver “comfort care” meds.
My mother-in-law had a history of esophagus problems, and everyone felt that she was probably uncomfortable with the tube.
She lived less than 48 hours after the respirator was removed.
She was not in a persistent vegetative state (comatose for a year or more), but none of us, not even the doctors, were really sure how long she might live after the respirator was removed.
I bring up the specifics only because I think there is a tendency among Commonwealers, who tend to be a brainy lot, to speak about Church teaching as theological or intellectual exercises in public or moral policy, rather than on how it plays out when a family is under extreme duress and a loved one cannot communicate.
Another complication for some Catholics is that we live in “mixed” families, where there are family members who are not Catholic and will not fall in line with Church teaching.
In those cases, I think we have the obligation to tell parents and siblings, for whom we may have power of attorney, that we must act according to the Church’s teachings–which may not allow us to carry out certain end-of-life wishes.
This has been an extremely difficult road to navigate with my own family as my father struggles with his final illness. There have been times when my family views me as heartless and self-righteous. This is very difficult to deal with on top of the grief of watching a beloved parent die.
This is a wonderfully respectful and focused discussion.
Does Paul have further reflections in light of the contributions offered?
Thanks, Jean, for pointing up some of the more troubling aspects of this statement (hiccup?) from the CDF. I certainly hope these distressingly simplified responses to the USCCB’s questions, including the minimal explanation in the “Nota,” do not constitute the totality of the CDF’s reply. What happened to the traditional criterion of the likelihood of recovery? Why should competent medical authority be dismissed? Aren’t there mitigating circumstances between the ideal situation and “extreme poverty” and extremely rare circumstances? What are we to make of the relationship between John Paul II’s 2004 statement on PVS and end-of-life care, with its call for “awakening centers,” and his own decision about the end of his life? This matter is most pressing; this method of addressing it is not terribly helpful.
Thanks for the thoughtful and respectful interaction. A number of people wondered what I meant when I said that pastorally this teaching is a nightmare. I suppose my concern is that the complexity of end of life issues is just lost when we get questions posed and answered in this un-nuanced way. I think a person can be absolutely committed to the value and dignity of human life and believe that this teaching is profoundly wrong. Surely, we can imagine a situation in which a family member loves his son or daughter, or mother or father, believes that his loved one is still a person who deserves respect, does not want to see the life come to an end, but also believes that requiring a feeding tube to remain connected, perhaps for decades, is to be a hostage to the technology in a way that is at odds with their deepest faith commitments. If the person’s loved one also expressed a clear desire that he or she did not want to have death prolonged in such a case, the situation could feel like torture.
I know that a little knowledge is a dangerous thing. And here my knowledge is indeed little. But let me ask for comment on the following line of thought.
An old principle of Roman Law that what influential in at least some relatively recent versions of Canon Law was: Prohibitions are to be interpreted strictly, permissions broadly.
So, in the present context: Joe Petit, nothing’s said about air. This CDF document is therefore not applicable to the air question.
Furthermore, all the “exceptions” in the CDF document ought, if this principle is applicable, to be interpreted broadly.
There’s more to this kind of casuistry that may well be applicable here. But let me stop for now.
It’s interesting to note that throughout the questions, answers, and commentary from the CDF, there are always quotation marks around the terms “vegetative state” and “permanent vegetative state.” This is a convention to denote irony or skepticism, which is no doubt warranted, given the fact that consciousness is largely a mystery and “vegetative state” is more a clinical description than an analysis and explanation of what precisely is wrong with any particular patient. So given the unknowns and the uncertainties here, I am amazed at the tone of utter certainty from the CDF about what kind of treatment is warranted for people in a persistent (or even permanent) vegetative state. They make it all seem so simple!
When Karen Anne Quinlan’s parents wanted to withdraw her from a respirator, they had the support of their priest. When the respirator was withdrawn, she was able to breathe on her own, to the surprise of everyone. One distinction between air and nutrition is that breathing is involuntary while eating and drinking are voluntary — obviously essential but not automatic.
What to make of this distinction? I don’t know, except to say that it seems an artificial one because the level of intervention for one is often no more and no less than for the other. Indeed, artificial feeding might be more invasive depending on the circumstances. We aren’t talking in most cases about feeding by mouth or even by nasogastric tube, but by parenteral nutrition. I vividly remember watching a documentary about the Cruzan case, in which a protester was able to make it inside the hospital and kept asking everyone in sight if he could offer Ms. Cruzan a cup of water. If he had tried to give Ms. Cruzan water she probably would have choked and died from asphyxiation (like my own grandmother did, in a hospital).
I am not going to editorialize.
I suspect that one key issue is whether giving nutrition and hydration by artificial means is medical treatment. There are well established grounds for refusing medical treatment either in person or by proxy. At least this was a question in earlier presentations of this issue that I recall and ecclesiastical spokespersons seemed determined to insist that giving nutrition and hydration by artificial means is not a form of medical treatment. That claim seems at least doubtful to me.
Let me just ask this:
Is it the nature of the intervention that matters or the purpose of the intervention?
Oxygen and nutrients are equally important (arguably the former even more so than the latter!) for life. The “purpose” of intervention, IMHO, is absolutely the same whether one is artificially sustaining respiratory or alimentary functions.
How they are administered does differ, but in cases where a person cannot feed themselves, usually, what is meant is that they cannot swallow and some cases cannot even digest food in a manner that is safe. Thus, for all practical purposes, intervention must be “medical” if you are to give any common sense meaning to that word.
Is the issue here, really, that when you withdraw respiratory support, the person dies within a relatively very short period of time? Is that really what is motivating this distinction?
Bernard: I appreciate your point, but the purpose of my raising the air issue was not to put something else on the table, but rather to explore the “treatment” vs. “care” distinction. The new statement still allows for withholding/refusual of treatment but not of care. What counts for bodily care seems to be a “basic needs” criterion. The body does not need chemo, and so it may be refused, but the body does need food and water. On this logic, it seems that air would also fall under care.
This problem is identified in the first of the two articles linked above by William Collier. I find it to be a very good argument. Barbara also keys in well on the means of delivery. If we can be expected to provide hydration by means of an IV, then why should we not provide oxygen by means of a machine that bypasses the lungs altogether (such a machine is used for infants who inhale micomium in utero, and would otherwise die after birth without this machine)?
It is precisely this treatment vs. care distinction that many argue is novel in recent Church teaching. If the logic of the distinction has not been fully explored, then the distinction itself has not received a full consideration. I suspect that many people who support long term food and hydration might at least think twice before adding yet another machine to which a body must be hooked.
I think it’s legitimately difficult to generalize on this topic, so let me raise two more possibilities:
Dialysis, unlike chemotherapy, also replicates a normal bodily function. Should a person be required to accept dialysis because it is simply mimicking what the body does naturally, even when (as it sometimes does) becomes a form of torture, given the advanced state of their disease?
I don’t think so, obviously, so I think that distinction (i.e., the purpose distinction) is not viable. In many cases the purpose of medical intervention is to do artificially what the body does not do for itself.
In the case of nutrition, the distinction that could be made is that it is, if not routine, certainly normal, for people to be fed by others — e.g., infants. In other words, we cannot as humans breathe or dialyze for others but we can certainly supply others with nutrition, though, I would hasten to add, not if they can’t swallow or digest food. Then, in fact, we must turn to medical intervention. In other words, it’s not the purpose of the support, but the mode of delivery, in which case, I think the distinction that has been made is not entirely correct.
Also, of course, it is the nature of the support in conjunction with a whole host of other factors, potential for recovery and baseline status certainly being two of them. Remember, in all cases, this should only ever be an issue where the individual cannot give knowing consent. If an individual in need of support decides to buck the Church, that’s their affair as far as I am concerned. It’s for the protection of those who cannot give consent that this really matters.
Barbara: I think the difficulty of identifying precisely the distinction between things like feeding, providing air, and dialysis shows that the distinction between treatment and care is not a helpful distinction. Yet, the requirement for food and hydration rests entirely on this distinction being clear and coherent.
Yes, we have a history of feeding people who need assistance and providing them with drink. These are clearly good things to do. However, ususally when we do these things, the person is not a PVS. Usually, the person is not dying. To transfer the kind of neighbor and family care a Christian should provide to anyone in daily life to duties to a body with no hope of recovery is just not clear thinking. It is sentimentality. If the criterion for end of life care is the suffering that can be caused by not providing the care, then, in fact, dialysis, respiratory assistance, and all sorts of other things would be called for.
The burden seems to be on those who would defend the distinction between treatment and care to do make the defense strong and clear. If this cannot be done, authoritative claims on issues with the gravity of end of life decisions should not be made on the basis of this distinction.
Barbara and Joe Petit: What follows has reference only to the CDF document at issue here. I take it that this document is a piece of legislation. It’s main objective is to tell us how we should act in certain specific circumstances. If this is correct, then it is legislation dealing only with nutrition and hydration. No matter how analogous dialysis or the machine supplied oxygen is to hydration or nutrition, they are not covered BY THIS LEGISLATIVE ACT. Whether the analogy among these four things is so overwhelming that one would have to conclude that what applies to one of them applies to the others can perhaps be shown by some line of argument. But absent that conclusive argument, I am not bound to presume that the purported analogy has this kind of force. In this case, I think that there are sufficient disanalogies to conclude that, not even by implication, does this piece of legislation cover mechanical oxygen support.
Furthermore, the CDF response to its own first query is certainly insufficient to be action-guiding in at least some particular cases. I myself doubt that it is sufficient to be action-guiding in most cases. If this is so, then there is room for various interpretations. When there is this kind of room for interpretation, then it is a matter for practical reason to determine how the particular case at hand should be decided and what action is either obligatory or permissible.
So I see the relevance of the lines of argument that each of you has presented in your posts above. I do not see that any of them scores a clean knockout. Indeed, in matters of concrete action, I doubt that there knockout arguments that tell one what he or she must do, though there can, in some simple (i.e., non-complex) cases be knockout arguments to say what one must never do. For example, one must never blaspheme or deliberately kill a newborn baby.
Precisely because of these difficulties in resolving particular cases of how we ought to act, the important discipline of casuistry was developed. Unless I am badly mistaken, what our Supreme Court does in deciding particular cases is to engage in the art of casuistry. When there is a case for which there is no need for casuistry, it generally refuses to consider it.
I doubt that the statement by the CDF is a piece of legislation. Rather it seems to be an application of the general requirement for due respect for human life, or, to put it negatively, the commandment thou shalt not kill’ to a particular situation. If I am correct, then it is legitimate to ask by what logical steps from respect for human life, which we would all agree is a primary value, the CDF gets to its position. And it may be useful to consider cases that seem to be analogous.
Joseph Gannon: I do agree, Joe, that it is legitimate for us to ask about the logic of the CDF statement. That is certainly worth doing. But it does not follow that if I find an argument that convinces me that machine supplied respiration ought to be treated the same as hydration and nutrition that I should treat my conclusion as having. in the absence of any further decree from the CDF, as having the same force as its present document does on hydration and nutrition.
The CDF document does not aim simply to show what it thinks follows logically from respect for human life. It aims, I presume, to be action-guiding. In that sense, given the mission of the CDF, this document deserves to be treated as legislation. So far as I can see, it claims no more than to say how we should deal with hydration and nutrition. Not being part of this legislating body, I do not have reason to claim that what I take to be the logic at work in the document ought to be extended to GUIDE ACTION in cases of respiration, dialysis, or anything comparable.
But why should anyone base their actions on something that is illogical? The CDF isn’t like Congress, it doesn’t have an enforcement arm at its disposal. At any rate, here is for me the compelling issue: is it now the CDF’s position that a Catholic hospital should force its patients to accept nutrition/hydration even if it requires surgical intervention? So if I go to a Catholic hospital, I can decline surgery or external medical intervention if it is required for me to breathe but not for me to obtain nutrition? Do you see the problem here?
Hi, Barbara, you wrote:
< < Dialysis, unlike chemotherapy, also replicates a normal bodily function. Should a person be required to accept dialysis because it is simply mimicking what the body does naturally, even when (as it sometimes does) becomes a form of torture, given the advanced state of their disease? >>
Prefacing my reply by once again noting that I don’t claim any particular expertise or insight into this decision-making:
It seems that the distinction between nutrition/hydration and dialysis is one of cause and effect between the medical condition and the care: the patient’s inability to feed herself is directly related to her vegetative state, but most vegetative patients presumably have kidneys that function without dialysis.
To put it another way: if a patient who is vegetative requires dialysis, at that point his vegetative state ceases to be the relevant category for moral decision-making: at that point, he is a kidney patient.
Jim,
As I see it, the relevant condition is “need of care” not the state the person is in. Yes, someone in a PVS is in need of the care of nutrition and hydration because they cannot do it by themselves. But the relevant issue is the need not the state.
Needs are relative phenomena. I may have a need to slow the spread of cancer, but I also have a need for bodily integrity that is threatened by chemo. I must balance those needs, and so which needs are more important is relevant to my balancing of them. Bodies certainly have needs for things like nutrition and hydration; ultimately, however, persons have a need to be allowed to die. That someone chooses the latter over the former is not an indication that the person somehow fails to appreciate the needs of the body or to respect life. Not all needs can be met.
Jim,
As someone pointed out previously, the CDF says that “in some rare cases, artificial nourishment and hydration may be excessively burdensome for the patient or may cause significant physical discomfort.” But given that one of the clinical criteria for the diagnosis is “no evidence of awareness of self or environment; no interaction with others,” how can can ANY treatment be excessively burdensome or uncomfortable?
You may be correct in saying that a person in a persistent vegetative state who has kidney problems should be thought of as a kidney patient, but since the principal criterion for withholding dialysis would be if it were unduly burdensome to the patient, it is difficult to see how dialysis (or any other treatment) could be withheld. What constitutes an undue burden on a person who has “no evidence of awareness of self or environment”?
Jim, no, although at first blush that is an appealing distinction, I do not believe it holds up. A PVS person’s need for dialysis is almost certainly going to be evaluated in terms of their PVS state, and not just the diseased state of their kidneys, just as the need for alimentary support is. To put it another way, if Terri Schiavo had needed dialysis rather than artificial alimentary support, should the Church have shrugged its shoulders at the decision to withhold it simply because it involved the functioning of an internal organ? (The answer is, I hope, “No.”) Elevating food and hydration above other treatments has the potential to do two things: first, to require some who otherwise might be dying to prolong their lives with unwanted treatment; and second, to dismiss other types of treatment as being somehow less ethically imperative because they constitute “medical” intervention. I don’t like either outcome, the trick is to find a logical and convincing distinction.
Hi, David Nickol, you wrote:
< < You may be correct in saying that a person in a persistent vegetative state who has kidney problems should be thought of as a kidney patient, but since the principal criterion for withholding dialysis would be if it were unduly burdensome to the patient, it is difficult to see how dialysis (or any other treatment) could be withheld. What constitutes an undue burden on a person who has "no evidence of awareness of self or environment"? >>
It’s a good question, and I don’t know the answer. If it’s a matter of experiencing pain, and the patient isn’t able to communicate that she is in pain, it seems a conundrum. If it’s a case where successive treatments cause the patient’s vital signs to deteriorate over time, perhaps medical professionals can use that data to try to come to a somewhat objective conclusion about the treatment’s burdensome quality.
Just speculation on my part – I really don’t know. Maybe a medical professional could comment.
Hi, Joe Pettit, you write:
<
Needs are relative phenomena. I may have a need to slow the spread of cancer, but I also have a need for bodily integrity that is threatened by chemo. I must balance those needs, and so which needs are more important is relevant to my balancing of them. Bodies certainly have needs for things like nutrition and hydration; ultimately, however, persons have a need to be allowed to die. That someone chooses the latter over the former is not an indication that the person somehow fails to appreciate the needs of the body or to respect life. Not all needs can be met. >>
Joe, in your view, is a person in PVS a terminal patient? I may be misreading your thoughts, but is seems that’s an undercurrent running through them.
I alluded to this somewhat obliquely at the top of the thread, but let me try to highlight it here: In the Schiavo case, the church’s public stance seemed to hinge on the conviction that PVS patients should not be thought of as being terminally ill merely by virtue of their vegetative state. (Whether or not the autopsy in the Schiavo case ultimately supported or refuted that assumption – and I don’t honestly remember whether either is the case – it seemed a defensible position at the time).
But the way the US bishops framed the question to the CDF, it was not specified whether or not the patient is terminal. It only stipulated that he is vegetative.
My (admittedly sketchy) understanding of church teaching about withholding extraordinary treatment, is that these decisions come into play only if the patient is terminally ill. (True?)
< < A PVS person's need for dialysis is almost certainly going to be evaluated in terms of their PVS state, and not just the diseased state of their kidneys, just as the need for alimentary support is. >>
Hi, Barbara,
The chain of reasoning that I see from the CDF goes something like this:
* All patients -whether vegetative or not – are entitled to basic care, such as food, water, warmth and cleanliness. Such basic care should be understood as a basic human right, and so even a PVS patient is entitled to it, because she possesses the same human dignity as any other human being, despite her considerable functional deficits.
* In the specific case of vegetative patients, the patient cannot provide food and water for himself because of his condition.
* Therefore, it is incumbent on others to provide this basic care to which all humans have a right.
Is dialysis in the same category? It’s difficult to see why, for two reasons:
1. There is no necessary cause-and-effect connection between a vegetative state and a kidney ailment – the vegetative state does not *cause* the kidney ailment (at least not according to my extremely rudimentary medical knowledge – in fact, in my case, to describe my medical knowledge as “rudimentary” is probably to oversell it!). I’m not denying that a patient may be both vegetative and have defective kidneys simultaneously. But does the one *cause* the other?
Why is this important? I suppose because hovering in the background of these vegetative cases is the question of whether or not the patient is terminally ill. Istm that an underlying presumption for the church is that PVS is not intrinsically a terminal illness. If PVS causes something like kidney failure, then that assumption is questionable to say the least.
2. A kidney ailment is an ailment, in a different sense than malnutrition is an ailment. It’s the difference between a physical ailment and a sin. if my sister is hungry, I have sinned; but her kidney can malfunction through no culpability of mine or anyone else’s. Consequently, my moral duty toward her in the former case is of an entirely different order than in the latter.
Humans have a right to food; it is not (by the standards of medical care in the 1st world) an expensive or scarce resource; the bishop framed the question to conveniently exclude those patients for whom it would be a burden; so why wouldn’t we provide it to a patient who is hungry?
I do see that, when it is provided via a feeding tube, nutrition looks just like other forms of medical treatment; requires the intervention of medical professionals; shows up as a line item on a hospital invoice; is covered by insurance for those lucky enough to have it; etc. Nevertheless, despite those external similarities, my reading of the CDF document is that it is of a different moral order than dialysis.
Jim: Perhaps this aside is irrelevant, but I offer it anyway.
Many of my students will start my classes thinking that whatever happens is God’s doing. I tell them that they do not really mean that and to prove it, I offer to draw grades for the semester for each one of them out of a hat. The students are quick to say that if I put lots of A’s in the hat they will accept. I point out that they are selling an omnipotent being quite short. I clarfiy that even if I put all F’s in the hat that God could change the F to the appropriate grade before my eyes had a chance to read the paper. At this point, I make the offer again, and no student takes me up on it (thank goodness!).
I have absolutely no stake in words like “terminal.” If a physician gives her or his best interpretation of a situation and were to say that I have no chance for recovery, or even almost no chance, and other doctors agreed, I would VERY much wish for ALL forms of support, except perhaps pain medication, to be withheld. I would want to die. I would want my family to have the closure of my death, rather than the agony of my suspended death. I would not need the irony of relying machines to give God more time to intervene. I suppose anything is possible, and no one is technically terminal, but I am not going to make my decisions based on the possibility of a miracle.
So, no, my position does not rest on the notion that the person is “terminal.” Rather, it rests on the notion that whatever matter of care/treatment is under consideration, I will reject it if it is very, very unlikely to not to change — and not simply to maintain — my condition.
Sorry, that should read, “very, very unlikely to not change.” My neighbor turned 40 today and the block has an impromptu party under way.
A short comment on the Sept. 17 postings on this topic.
Except for Barbara’s 8:35 message, all the other messages seem to me to confirm that the CDF statement, as it stands is not sufficient to be action-guiding in many, many cases. Accordingly, again, given the complexities that these messages bring to light, practice will have to involve applying casuistry to the CDF statement as it stands.
I, for one, am glad that the CDF statement made no attempt to determine more precisely a norm that it would have applied to most cases.
Re Barbara’s *:15 posting: Just two remarks.
1. I believe that you would agree that at least some Church rules, e.g., that people in the appropriate age category ought, under normal circumstances, fast and abstain on Good Friday, is binding even though there are no cops to enforce it.
2. Perhaps you would not agree, but I would argue that even if a law L forbids actions a, and b, and that action c is logically indistinguishable in all relevant matters from a and b, that said Law L does not forbid c. It is simply silent about it. The alternative to my position is that I, in trying to observe Law L would be held responsible for deducing what else the explicit text states. So far as I can see, that requirement would fly in the face of the norm that for a law to be binding in any moral sense, it must be sufficiently promulgated by the legislating agent.
I know that this comment does not address any medical considerations. Nonetheless, I think it is important, in this context as in many others, to get clear about just what the CDF has said and what its binding force is. In this case, it does bind us to consider just the items (nutrition and hydration) and the qualifiers that it states.
The John Paul II/CDF commentary stance on nutrition and hydration are a marked shift in Church teaching.
In the traditional stance of the Church, the distinction of ordinary/proportionate vs. extraordinary/disproportionate were gauged in light of their effects on the patient considered holistically, in his or her physical, psychological and spiritual state, and in the light of the resources of the community involved. These are not technological distinctions, but human distinctions. It is the shift in teaching by John Paul that has reduced this to a discussion of what machinery or techniques are considered “ordinary” instead of what counts as good care of the person understood holistically.
This is important because the shift to a technological standard for “ordinary” care runs the risk of sinking into biologism, the notion that mere biological life is the criterion for human dignity. Christian tradition resists biologism, because it is at heart a materialistic and non-contextual view of human life. Certainly this or that technique can prolong the life of someone no longer capable of living without technological aid. This is true of respirators, dialysis and nutrition and hydration by artificial means. But is the person aided?
Consider a person with advanced Alzheimer’s disease. At some point in the disease, well after the patient has lost the capacity to recognize or respond personally to others, the patient ceases to be able to swallow without choking. A peaceful death will follow in days if the natural course of the disease is respected. A feeding tube will sustain biological life for weeks or months longer, with the risk of self-injury if the patient pulls on the tube, and with the risk of infection. Feeding the patient will not allow him or her to regain the capacity for meaningful interaction with others or enjoyment of life: that capacity is gone. The burden to the family in situations like this can be intense. If the patient is irritated by the tube and pulls or tugs at it, he or she may spend his or her last days in restraints. There is only the possibility for burden (pain, infection, the on-going agony of the family,) not pleasure, human connection or hope of recovery for the patient. The instruction explicitly mentions Alzheimer’s as a case in which feeding and hydration would be obligatory. But is there reasonable hope of benefit to patient and family? And is the dignity of the whole person respected when biological life is sustained without benefit to the patient?
Maybe it’s just the nature of the forum that it’s difficult to develop this issue, but I don’t think it’s logical to conclude that a PVS person’s life is worth enough to mandate (whatever that means) intervention including associated medical treatment required to implement or continue it in order to administer nutrition but not lifesaving medical care. If you don’t like the example of dialysis, use any other medical condition: pneumonia, breast cancer, what have you. PVS patients get sick like you and I do (actually, probably even more so), and these illnesses are not directly related to their PVS state. I will stick to what I see the relevant distinction: if it requires something more than a feeding tube (which I don’t consider to be a form of artificial nutrition) it is medical treatment even if it delivers hydration and nutrition. No other position makes sense to me. Whether that or any other treatment should be “required” is, to me, the part that the CDF doesn’t want to address, ergo, it seizes on the difference between nutrition and medical care, a distinction that doesn’t make sense if you think that medical care, like nutrition, should also be a human right. The real issue is, what does it mean to be human? Is it just the ability to carry out mere biological processes, which the preceding post commented on much more ably than I could.
< < Whether that or any other treatment should be "required" is, to me, the part that the CDF doesn't want to address, ergo, it seizes on the difference between nutrition and medical care, a distinction that doesn't make sense if you think that medical care, like nutrition, should also be a human right. >>
Right; I do see that, Barbara. Not sure what the distinction here would be, except that medical care is a human right that comes wrapped in all sorts of qualifiers, caveats and degrees.
It appears that the CDF essentially is cutting away all of the complications in the matter of nutrition and hydration: food and water, it would seem, are a human right without qualification. Or, to be more precise: a patient’s vegetative state is does not qualify that right. (Even that seems problematic; my interpretation of their ruling is that throughout it that there is an implicit ” … and is not dying”.)
Barbara,
You said, “I don’t think it’s logical to conclude that a PVS person’s life is worth enough to mandate (whatever that means) intervention . . . .”
Isn’t that the whole point? Is it up to you or I or anyone person to decide what any person’s life is “worth”?
Professor Fullam’s comment is quite accurate, I think. For people who want further background on the salient issues, I’d recommend three articles:
Paul Ramsey, Patient as Person (New Haven: Yale, 1970), chap. 3 (“On (Only) Caring for the Dying”).
Kevin Wildes, S.J., “Ordinary and Extraordinary Means and the Quality of Life,” Theological Studies 57:3 (1996) 500-512.
Gilbert Meilaender, “Ordinary and Extraordinary Means: When Does Quality of Life Count,” Theological Studies 58:3 (1997) 527-31.
Sean, I am not saying that, the CDF is by implication, so take it up with them.
My cousin’s son underwent multiple surgeries in order to be fed through his (I think) small intestine in order to bypass his stomach entirely. He had a lot of other treatments as well. These are really hard cases, and I think ultimately treatment was stopped though I’m not clear, but I find it bizarre to sugges that evaluating the treatment for the feeding apparatus would proceed according to a different calculus than the other treatments.
Sean,
I believe you are misreading Barbara. I understand her to be saying, “How can the CDF say the person’s life is valuable enough for him or her to deserve all the medical intervention required for tube feeding, and then turn around and it is NOT valuable enough to require dialysis or some other medical treatment?”
It doesn’t quite make sense to say tube feeding and hydration are requred because they are “not medical treatment,” perhaps implying that all the effor that goes into tube feeding is mandatory (generally requiring surgery, almost certainly requiring nursing care, possibly lasting years), but possibly it would be permissible to withhold a simple and cheap dose of antibiotics to cure a life-threatening infection. (Can anyone deny antibiotics are medical treatment?)
Again, I think the primary problem with this discussion is that we’re talking legalistically and generally, and that’s not how most of us have to face these issues.
Lives are not “worthy” or “unworthy” of treatment. The person who’s lying there is someone we’ve known and loved very much. Every day my dad lives without a medical crisis is a gift for which I’m thankful. Every day he has to suffer is a day I hope, with dwindling intensity, that there is some type of grace in his suffering. A long illness is grueling, frightening and difficult.
The Church can say that, in most cases, people in persistent vegetative states should be offered food and water when they can tolerate it, to prevent what may be a painful death through starvation and thirst. Well and good.
But, at the risk of turning this into the Dead Relative Forum and repeating myself, what about when Ma cannot tell us whether the feedting tube hurts, or Dad says if he has a stroke and can’t communicate and doesn’t want to be “hooked up” to any type of sustenance?
The Church has put a lot of respect for life statements out there. My suggestion is that parishioners start asking priests NOW to provide discernment and guidance about how to live out such statements, particularly when there is likely to be family disagreement over how such situations are to be handled, c.f. , Terry Shiavo.
Jean,
Before this discussion, I thought I understood (without ever having made a study of it) the position of the Catholic Church on accepting or refusing medical care, and that would be what is summed up in the following:
**********
“The Church’s way has always been this sort of sane, Catholic, middle-of-the-road way. Because we have an ordinary obligation to respect our bodies as a gift from God, in most circumstances we have a duty to try to take health care, but we don’t have to go to absolute extremes and keep ourselves going even when it’s simply prolonging the dying process or is associated with grave suffering,” Brother Sulmasy told OSV. “On the other hand, that obligation means we can never kill ourselves or kill another person in order to put them out of their misery.”
Treatment is considered “extraordinary” if it is determined to be futile, meaning that it is either not going to work to keep the person alive or to reverse the course of the disease, or if the burdens of that treatment are disproportionate to the benefits.
**********
It seems to me each individual case where one would apply these principles is probably going to have its own unique circumstances, including each individual case where “vegetative state” is the diagnosis. It doesn’t seem particularly helpful to me to have a committee say, “When the diagnosis is X, you must take steps Y and Z.” There is so much more to each case than the diagnosis. I am leaning toward thinking that the CDF should state the basic principles, and leave the application in each individual case to the patient (if conscious), the doctors, the family, and the priests, ministers, rabbis, and any others consulted as advisors. These kinds of decisions are bound to be extremely emotional by their very nature, and a decision based purely on logical arguments by uninvolved, dispassionate outsiders may very easily be wrong.
I do wonder what steps the CDF took to educate itself about artificial nutrition and hydration or end of life issues generally. Giving examples can provide a lot of information, but I suppose this is not the way they do things.
I’m sorry if I misunderstood Barbara’s comment, but I do think much of the discussion is missing the central point that a person who is in a PVS is a) still a person, and b) not (usually) dying any more than say, a person with diabetes, or paralysis, or some other condition is “dying,” and therefore, implicit in many of the conclusions is that a person in PVS has a life not “worth” preserving.
Compare a person who is PVS but otherwise physically healthy and one who is quadriplegic and cannot eat solid food, but is otherwise conscious and can communicate. Can someone explain to me the moral distinction between them that would allow one to withhold nutrition any hydration from one but not the other that does not rely on the “value” or “worth” of their lives?
Sean,
I do not think it is obvious that a body in a PVS is a person. However, I do see clear signso of personhood in the quadraplegic person you describe. At the very least, I would see persons in two very different conditions, and while the value of both persons may be the same, it is not at all clear to me that respecting that value means insisting that a body be fed for years. However, I do see that respecting a conscious and communicative quadraplegic requires feeding and many other forms of assistance.
Sean, I humbly suggest that we need to get past dealing with end of life issues by trying to equate the legitimacy of treatment with assigning relative value to a person. Admitting that a person is dying and can never benefit from treatment, is not the same as saying that they have no value or less value as a person. I admit that these are often awesomely difficult situations, but unless we really believe that “valuing” people requires us to keep everyone going so long as they exhibit any biological activity, we need to confront end of life care, which in my opinion includes medically feeding and hydrating people. Honestly, in those situations I’ve been confronted with, letting go was, to me, the harder and ultimately more humane option. But it will never, every be easy. I think that’s why I find hard and fast rules to be so frustrating. They are ducking the true dilemma.
Joe,
That is a good answer, but it is based on a factual distinction, not a moral one. It shows my point. You must assume one is not a person, or has less value as a person, to justify not feeding him or her.
Barbara,
You and others are assuming facts. The question is not about “end of life” issues, but of treatment of a severely disabled persons. The Church is not, nor has it ever been, for keeping terminal patients alive by all means and in all circumstances, and that is not what this CDF answer was about. PVS is a physical condition, it does not describe a terminal condition.
Sean: You think it is obvious that denying nutrition and hydration to a body in PVS amounts to a devaluing of the person. I, and others on this thread, simply do not agree. I see a difference between life and living. I clearly do place less value on the living that takes place in PVS, but that does not mean I value the life less. Imagine this monologue:
“Huh? Where am I? Oh man, looks like I am in a permanently vegetative state. Shoot, I sure would have preferred to go out in a much more straightforward way. Well, it looks like I have one last struggle: getting through the death of this body of mine. That’s O.K., I guess. I have had many struggles in life: acne, girlfriends, raising kids, writing a dissertation, depression. This death of the body thing should be manageable. The one thing I hope nobody does is prevent me from going through this last struggle by hooking me up to nutrition and hydration. Sure, not having those things will hurt, but I hear pain meds are pretty good these days. I don’t mind hurting, but I do mind just being in this bed for twenty years. Surely nobody who knows me will let that happen to me!”
Sean, I don’t see the kind of nuance that you do in the CDF statement. Let’s leave it at that.
Joe,
The point, I think, is that the Church is telling us that none of us are equipped to make the distinction between “life” and “living.” Once we start down this road, there is no logical stopping point – just individual opinions about values. Is a profoundly retarded person’s just “life” or is it “living”? What about someone with MS? What about a quadraplegic? I am not saying that being in a PVS is good or valuable, but that human life is an absolute good and you or I are in no position to decide when any individual life’s value is no longer “good” in this absolute sense. That’s God’s call.
Barbara,
I see nothing nuanced about it. I was merely pointing out that the questions and answers said absolutely nothing about end of life care or the treatment of persons in terminal conditions, so I don’t see how it can be seen as some sort of departure from Church teaching as to these subjects. In fact, I think it was a very straight forward answer to a very straight forward question.
Suffice it to say, that I disagree, because by declaring flat out that nutrition however delivered is not a form of medical care, I do think the church can now be said to be mandating extreme treatment in circumstances where it formerly did not. That’s as simply as I can state my objections.