The old adage that hard cases make bad law is often true, but it is also true that hard cases can help crystallize fundamental moral issues. Thus, at the risk of reviving the painful passions that swirled around Terri Schiavo’s death, I want to ask whether that incredibly hard case helps us identify core moral questions about end-of-life decisions.
Can we learn anything morally useful from the Schiavo case? For example, was the strong, public opposition among some prominent Catholics, including some bishops, to the removal of Schiavo’s feeding and hydration tubes an indication that church teaching about end-of-life care has changed?
To answer these questions, we need to look carefully at the claims of those who condemned the removal of Schiavo’s feeding tube as morally repugnant, for behind the highly charged rhetoric that frequently accompanied such condemnations rests a core moral conviction that bears examination. Consider, for example, the claims made by various hierarchical officials and their spokespersons, both here and abroad. Bishop Robert Vasa of Baker, Oregon, said that it would be “murder” to remove Schiavo’s feeding tube. Cathy Cleaver Ruse, the director of planning and information for the Prolife Office of the United States Conference of Catholic Bishops (USCCB), suggested that Schiavo was executed, and Cardinal Javier Lozano Barragan, the head of the Pontifical Council for Health Care, claimed that Schiavo was not allowed to die, but was killed. To put these claims in terms of traditional Catholic moral teaching, all three are, in effect, saying that removing the feeding tube from Schiavo was an act of euthanasia, which the church explicitly condemns.
To see what assumptions are embedded in the claim that Schiavo was euthanized, it is useful to consider the definition of euthanasia set out in the Vatican’s 1980 Declaration on Euthanasia. According to the declaration, euthanasia is “an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated. Euthanasia’s terms of reference, therefore, are to be found in the intention of the will and in the methods used.”
Framed in this way, the Schiavo case throws into sharp relief a central moral question raised by the prospect of withdrawing a feeding tube from any patient in a persistent vegetative state (PVS). Do we inevitably intend death when we remove a feeding tube from a PVS patient? Many critics of the action Michael Schiavo (Terri’s husband) took have wanted to answer yes. Take, for example, bioethicist Gilbert Meilaender’s exchange with Robert D. Orr in the August/September 2004 issue of First Things. According to Meilaender, Christians have traditionally said that treatment may be removed from patients when the treatment is either useless or excessively burdensome. The problem in the case of PVS patients is that, almost by definition, a feeding tube cannot be burdensome to the patient, and it does not appear to be useless. As Meilaender puts it, given that a feeding tube “may preserve for years the life of this living human being,” how can the treatment be said to be useless? Given that a person in a persistent vegetative state is, strictly speaking, not dying, it is hard to see how we could be merely letting that person die when we remove the feeding tube. Indeed, says Meilaender, in the circumstance of removing a feeding tube from a PVS patient, we seem not to be aiming to end a useless treatment, but to end a useless life. And this is precisely what Christians must resist.
I will come back to this point shortly, but it is important to see that Meilaender is not alone in making this argument. I suspect, for example, that something like this conviction stands behind the claims of the many Catholic commentators who cited Pope John Paul II’s March 2004 allocution on nutrition and hydration in opposing the removal of Schiavo’s feeding tube. And, indeed, it is worth looking at the papal statement with this in mind.
Although some commentators have wanted to suggest that John Paul’s remarks did not break significantly with traditional Catholic teaching, Thomas Shannon and Jim Walter have persuasively argued that the allocution (and the Vatican statements that led up to it and have flowed from it) represents a shift in Catholic teaching. According to Shannon and Walter (see Theological Studies 66, 2005), among the changes that characterize the revisionist position is the view that providing artificial nutrition and hydration is obligatory. In making this claim, they point to a 1981 document from the Pontifical Council Cor Unum, Questions of Ethics Regarding the Fatally Ill and the Dying, and to the document Artificial Prolongation of Life by the Pontifical Academy of Life in 1985. Still, the defining statement of this shift is found in the 2004 papal allocution.
In the key passage, John Paul makes two claims. First, providing nutrition and hydration is a form of care, not a form of treatment. Second, withdrawing a feeding tube is essentially to aim at death. With regard to the second point, he said: “Death by starvation or dehydration is, in fact, the only possible outcome as a result of this withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission.”
What should we make of this claim? The first thing to note is what is not being said. John Paul does not assert that removing a feeding tube is directly to kill the patient. In terms of the definition of euthanasia set out in the Declaration on Euthanasia, removing a feeding tube is not an action “which of itself” causes death. This is important because if removing the feeding tube is not wrong per se, then, if it is wrong, it must be so because of the intention of the will in removing the tube. (Recall that the declaration defines euthanasia in reference to “the intention of the will and in the methods used.”)
This distinction takes us back to Meilaender’s claim that in removing a feeding tube from a PVS patient we necessarily aim at death. Is Meilaender right about this? It certainly appears to be a plausible claim. After all, as both Meilaender and John Paul note, death is the certain outcome of removing the feeding tube from a PVS patient, a patient who is not imminently dying. Yet appearances can be deceiving.
No one has diagnosed the confusion here more perceptively that Daniel Callahan in his important book, The Troubled Dream of Life. According to Callahan, modern medicine has come to see death as an enemy that must be fought by any and all means. And because medicine has been so enormously successful in combating the causes of early death and thereby lengthening the average life span, we have come increasingly to act as if death is not a natural fact of life, but a failure of human will. From a traditional fatalism in the face of the biological realities of human embodiment, we have moved to a moralism that condemns every concession to human finitude as a moral failing. Indeed, says Callahan, we have lost any sense of nature as acting independently of human choice, as if no death that could have been prevented could be anything other than the result of an intentional act.
Thus, to say that removing a feeding tube from a PVS patient is necessarily to aim at death is to conflate human action and natural events. It is to fail to recognize that dying is commonly associated biologically with a natural inability to eat or drink. If we do not conflate human and natural causality, it is perfectly sensible to say that a person suffering from a severe brain injury who cannot eat or drink is in fact dying, even if we can intervene and postpone that dying for years. Not starting or stopping artificial nutrition and hydration in such a case is not necessarily to aim at death, though one could intend death in such circumstances.
To conclude otherwise, it seems to me, is to succumb to a sort of hubris that repudiates any natural limits on human action. Callahan has captured the irony of this situation perfectly. “In the name of the sanctity of life, many who would consider themselves conservative and supporters of traditional religious values are forced into a slavery to medical possibilities, held in thrall by the false gods of technology.” The irony is particularly striking in relation to the Catholic commentators (Meilaender is not Catholic) who appear to adopt the Promethean attitude toward human embodiment and finitude that the tradition has long rejected.
There was a time when it would have been possible for Catholic writers, with the full weight of magisterial teaching behind them, to say that a life lived in a state of permanent unconsciousness with no apparent hope for a spiritual or social life was a terrible prospect, one that no person was obligated to embrace. In traditional Catholic teaching about the end of life, letting nature take its course in such a case made sense, not because such a life was regarded as worthless, but because in such a circumstance we confront the limits of human powers in the face of human vulnerability.
Both the view that providing nutrition and hydration for PVS patients is morally obligatory, and the position that providing a feeding tube is a form of care and not treatment, represent a shift in Catholic teaching. Understandably, commentators who have noted this shift have sought to downplay its significance, perhaps hoping that the change will be confined to cases involving persistent vegetative states. My own view, though, is that the changes are much more profound than anyone has acknowledged. They threaten to dismantle not simply Catholic teaching on end-of-life issues but much of Catholic moral theology generally. When natural constraints on human actions are treated so cavalierly, when what we can technically do appears to determine what we ought to do, the wisdom of the tradition that recognizes the goodness of our embodied existence and the fact that mere existence is not an ultimate good, seems to have been lost. If the ordeal of the Terri Schiavo case helps us to recognize the possibility of such a loss, it will not have been in vain.