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From Catholic Healthcare West to Dignity Health Care

A harbinger of things to come? One of the largest Catholic health care systems in the country has relinquished its formal Catholic identity. I've talked to many people who think that the bishops can "make" a hospital be Catholic -or close them. But that's not the legal reality, at least in most cases. What will happen, in most cases, is some type of disaffiliation--the hospital will continue, in some form, although not an official "Catholic" facility. It doesn't affect tax exempt status, which most hospitals get through their not-for-profit charitable nature, not through their religious nature.

About the Author

Cathleen Kaveny is the Darald and Juliet Libby Professor in the Theology Department and Law School at Boston College.



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"...has relinquished its formal Catholic identity."So often relinquishing an institution's "formal Catholic identity" depends upon the instutution's religious community (in the canonical sense) or religious order that founded and sponsors the institution (and, in relation to that, whether their institution receives its tax status as a religious corporation, an educational institution or as a public trust). Obviously (for various reasons, possibly dwindling number of nuns among the reasons) the six religious orders that ran Catholic Healthcare West felt it was time to cut "formal" ties with the Catholic Church. For one thing, in the future, such fomerly Catholic hospitals won't have to worry about their Catholic status being revoked by a bishop (as St. Joseph's Hospital and Medical Center in Phoenix had last year).

Dignity.Excellent choice of names. As my age cohort (War Babies) and the one right behind us (Baby Boomers) get old, we worry about the loss of dignity which comes with having living wills and end-of-life directions ignored.If a hospital insists that a dying patient be forcibly fed and forcibly hydrated, against her/his will (in both senses of the word), why would that patient go into that hospital?

Just the first among many - and when do catholic universities start to go in this direction. Really, look at the Phoenix situation last year - what other recourse do they have in the face of certain bishops or even the USCCB?Their "catholic" mission will continue (with a little "c"); as you state, their legal/tax status will not change. But, they are freed from the current episcopal institutional narrative that gets in the way of their primary, gospel mission.

Dignity! Dignity?? Have they realized the problems that that name has with the uber-ecclesiastics?, the meringue will indeed hit the mixmaster over this one.

Jimmy Mac - I had the same thought. There is also an association of funeral homes called Dignity - perhaps not the connotation a hospital system desires :-)

So if it is no longer formally associated with the Catholic Church ... what is it?For a not-for-profit, its concerns - competition, market share, operating margin - seem pretty darn for-profit.

Humanae Vitae, the gift that keeps on giving.

Well, sure. Hospitals were Catholic because they were run and staffed by nuns. The nuns are gone; the Catholicism is gone.It will be a great loss for human beings, who were cared for with intelligence, respect, and kindness. The best thing about the Church in America was the nuns. That selflessness has gone from our world, replaced with bickering over social programs. Patients will just have to fend for themselves, as they sink in the system, either loudly, demanding their rights, or quietly, overwhelmed and exhausted. There will be no one there to care for them as human beings, children of God.

Good.I have no desire to go to a Catholic hospital, and avoid it where possible. Maybe having to battle with a bishop over his authority to dictate what medical care I must have or not have is something to avoid, period.Gerelyn has it right: If a hospital insists that a dying patient be forcibly fed and forcibly hydrated, against her/his will (in both senses of the word), why would that patient go into that hospital?I was asked to make the decision if my mother would have a burdensome procedure done to feed her artificially. She was not in any condition to undergo anything, after decades of congestive heart failure. It would have been simply cruel. I could see the doctor was greatly relieved I declined. She mercifully died four hours later. I have zero confidence that a Catholic hospital subject to the tender mercies of any bishop would have allowed my decision to stand.

Jim, hospitals are large institutions -- it's hard to plan and manage for the future. Having to respond constantly to the varying requests of BOTH Church and public authorities for compromises and future assurances and audits and special units with separate rent and separate personnel and funding just to make a transaction work means that the hospital is spending a lot of resources and brainpower threading needles in one tiny area of its operations that do not promote the provision of services to the larger community. You can sing all day about how sinful contraception is, but when you haven't convinced 90% of the relevant population sitting alongside you in the pews, you have a problem of authority. Making Catholic institutions the whipping boy in the debate because you can doesn't solve the problem and it is increasingly clear that many will exit if they can.

Barbara is right, too. I also think there is a moral issue here. In my view, Catholic health care would be virtually dead now if it weren't for sister McBride in Phoenix. If that mother had been allowed to die, I think the regulators would have descended on it. Many non-Catholics --and many Catholics believe that Bishops Olmsted is not a good decision-maker (and that was confirmed by later events)==getting him out of the loop was a good thing, not a bad thing.

Saw in today's paper that Christus St. Vincent in Santa Fe refused an abortion to a raped 12 year old girl.During Right to Life week here and while parental notification battles are fought at the legislature here, are we effectively preeaching the Gospel of Life to the total community?

Having spent some time in a Catholic hospital, I find the illusion that the institution can remain "Catholic" because an order of Catholic religious sisters once founded the hospital is, well, quaint at best.Hospitals, even on the smaller size, of the for-profit or non-profit variety, are big moneymaking operations - huge economic engines for the local economy in terms of jobs, services, and infrastructure. After the federal and state government, the Catholic hospital I referred to is located in a suburb in a large metropolitan area had the single largest payroll of any private corporation in the county. Every two weeks, this hospital's payroll dumped $millions into the local economy. More births occurred at this hospital than anywhere else in the state. We're talking $millions.This is not to say that the religious sisters who originally sponsored the hospital didn't try their best to maintain the Catholic identity of the institution through seemingly endless "mission effectiveness seminars" conducted for medical staff and employees. These religious women, who originally became involved in health care ministry when they responded to calls from Abraham Lincoln to nurse the wounded and dying during the Civil War, now had become corporate moguls in big business. It just that Jesus was right when he said that "no man can serve two masters" (Matthew 6:24). The poor religious women who founded these hospitals have become overwhelmed by the corporate imperatives that govern free market enterprise. There's no shame to this state of affairs - it's just the way our world works.In fact, it was one of the sisters of this congregation of religious women, whom I worked with, who eventually, as president of the sisters' own healthcare system, engineered the corporate takeover of the congregation's hospitals by a national non-profit corporation. The sisters apparently, facing diminishing numbers in their ranks, tried as well as they could but could no longer keep the hospitals' economic beast caged.But all that is only a backdrop to what has happened in Phoenix: As Cathleen Kaveny rightly points out, everyone especially the people of Phoenix who look to St. Joseph Medical Center for their health care needs are better off that Bishop Olmsted is now "out of the loop" when it comes to the medical decisions at St. Joe's.Only a very ambitious celibate hierarch could believe that it is a greater moral good for a mother to die due to complications from an unviable pregnancy and leave her other four children orphans for the rest of their lives. Ignorant politicians like Olmsted have no business being anywhere near the life and death healthcare decisions people have to make every day.Sr. Margaret McBride, like thousands of religious women before her, was an angel of healing for suffering women and their children. Thank you, Margaret.

David S. --Like you, I have a very high opinion of most nuns. But have you talked to any recently? Except for those belonging to very conservative orders, they are among the most liberal members of the American Church. And, yes, they were and are the backbone of the Church. But the hierarch and cnservative Catholics raised such a stink about that that they were recently subjected to "a visitation". But the joke was on their persecutors == the visitors found them in good shape theologicay :-)

I just want to add this: Barbar's point IMO is critical -it's about service(read also witness) and not being tied up in the varied demands in a small area.Footnote: a friend who I consider quite pro life said Olmstead is "crazy." I hearily concur.As Pogo said, "We have met the enemy...."

Wow! I cannot believe the poor understanding of Catholic teaching reflected in many of these comments. Gerelyn's and Carolyn's understanding is completely backward. The church teaches that you cannot withhold food, but it certainly does not require forcibly feeding a patient. No extraordinary means are required.And Bobs comment about the raped 12 year old fails on 2 grounds. First, the more helpless person here is the unborn child and second, that 2 wrongs (rape followed by abortion) do not make a right. Do not get me wrong, he describes a terrible situation and my heart goes out to the 12 year old. But abortion is not the answer.

@ Bruce LaFranchi: What you say are things that only could come from someone who doesn't have a uterus and is clueless when it comes to empathy for suffering humans. Hence, your referencing "Catholic teaching?"I hope this never happens to you [it is repulsive to even contemplate it], but let us know if you change your thinking IF your 12 year old daughter or granddaughter would ever be raped and become pregnant.And furthermore, no one, especially a woman with a unviable, complicated, medically dangerous, potentially lethal pregnancy would ever consider an abortion "the answer."Abortion is always a bad medical outcome. However, in life, many times the "bad" is more than likely better than the "worst." Unfortunately, we live in a reality where women must sometimes choose between a host of bad outcomes.For all the women out there who are faced with what must seem an impossibly bad choice, I always found solace remembering my sainted sixth-grade teacher, Sister Mary Adelaide, often quoting St. Paul: "For I am convinced that neither death nor life, neither angels nor demons, neither the present nor the future, nor any powers, neither height nor depth, nor anything else in all creation, will be able to separate us from the love of God that is in Christ Jesus our Lord."

Gerelyn,Nice story but off-target. The teaching is '... A feeding tube is not required, however, if it wouldnt prolong life, would be excessively burdensome for the patient, or would cause significant physical discomfort....'Not '... her nephew insisted the local bishops directive on use of feeding tubes required the Catholic hospital to install one. ...'

Jim,Thanks for your empathetic wishes and poignant observations about my body structure. As I said,'...he describes a terrible situation and my heart goes out to the 12 year old...' and I should have included her family as well.Unfortunately, basic biology teaches us that the fetus is a new human being. That human deserves its life regardless of how it started. That human did not choose to be conceived in that way anymore than the 12 year old chose to be raped. But both those things have happened. So now we have to make a choice, and I believe the lesser of the two evils is carrying the unborn child to term even though i know that will have a deleterious impact on the 12 year old and her life will be forever scarred by the experience. Btw, abortion is not a 'bad medical outcome'. A bad medical outcome is we operated but couldnt save the patient. An abortion is a good medical outcome, when thats the procedure you desired.

The Holy Father emphasized that water and food, even when administered artificially, are "a natural means of preserving life, not a medical procedure. Therefore, their use must be considered ordinary and appropriate and as such, morally obligatory."

"The nuns are gone; the Catholicism is gone."Do you actually believe that? Therefore there are no Catholic schools unless nuns run them. Therefore there are no Catholic nursing homes unless there are no nuns running them.What a narrow definition of what it is to be a Catholic anything.Therefore, there is no Catholic church because there are no nuns running it. (I can buy that one!)

Oops - s/b: "there are no Catholic nursing homes unless there are nuns running them."

A sad loss to the whole Catholic community, the many people of other faiths who relied upon 'Catholic' healthcare, and a definite disservice to the memory of the many sisters and religious workers who built and cared for so many individual community hospitals. The charitable and attentive care that always was in the forefront seems to be subjected now to bottom line economics. Dignity is a nice word, but Catholic means so much more.

Bruce and Gerelyn --It is my understanding that Pius XII did not require that food and water be given if someone were definitely dying, while JP II did. Another example of popes disagreeing.In fact, I don't think I have ever even heard of a Catholic hospital in this archdiocese force feeding a dying person. Maybe I'm wrong, but things like that do tend to become known where true. But from what is being said here, pparently there have been dioceses with very conservative bishops who have insisted on that policy. It would be interesting to study just how many dioceses required it, if any.

Bruce,Gerelyn's reference to the story is exactly on target. I prefer not to be in the position of arguing with the hospital over straining the gnats of interpretation of various policies when I or a relative's fate is at stake. Bottom line: the patient's directive was ignored. All the theory in the world is fine; it's how situations on the ground are affected in the moment. There are too many instances where horrors develop, despite countervailing smooth words.Please take time to read more of the 145,000 citations in Gerelyn's google search."Experts say no other large health systems in the U.S. have nutrition and hydration policies like those governing Catholic facilities. Catholic officials have said the directive is consistent with previous doctrine. But the revised language eliminates what many Catholic ethicists viewed as flexibility in its application to patients in a persistent vegetative state. The previous policy said there should be a presumption in favor of use of feeding tubes, rather than an obligation. Morever, according to Catholic officials and outside experts, the directive may well apply to a wider range of patients, those that it describes as having chronic and presumably irreversible conditions," though the organization representing Catholic health facilities downplays the impact. Experts say this affected group could include those with massive strokes, advanced Alzheimers disease, traumatic brain injury and Lou Gehrigs Disease....Dr. Lachlan Forrow, a Harvard University medical ethicist and palliative care specialist, expressed strong concern about the new policy, stressing its potentially broad scope. That gets to be a very, very large number of people, said Forrow, who heads a panel developing recommendations for the state of Massachusetts on end-of-life care."

Thanks, Carolyn.Here's a discussion of the Tulsa event: The last poster at that discussion says she thinks Catholic hospitals honor Do Not Resuscitate orders. I don't think people should take that for granted, either. E.g., doctors at Mercy hosptials are required to resuscitate. Agree that arguing with the hospital is not to be considered. The check-in person may assure an arriving patient that the hospital will respect her will and directives, but a nurse on the floor may have other ideas. The people who actually come in contact with the patient vary from hour to hour. What one says, the next may deny or ignore. Etc. Why add the possibility that end-of-life directives will be overridden to the already difficult situation?

Gerelyn and Carolyn,I think below are the relevant paragraphs. Reading 145,000 more citations does not add anything to the argument. Because the nephew, who was her health proxy objected, all hospitals, regardless of their affiliation, would have faced the same problem. Once the patient cant make a decision, the proxy controls regardless of previous paperwork. And I believe thats primarily because there is no certainty in these situations. No one can predict the future or what the outcome of various procedures or lack of action will produce. Its entirely a judgement call.But the patients nephew, her designated proxy, demanded that a tube be inserted, citing a September 2008 letter written by Tulsa Bishop Edward J. Slattery, who ordered Catholic health facilities in his diocese to provide artificial nutrition and hydration in such situations. Slattery relied on a 2007 statement by the Vaticans Congregation for the Doctrine of the Faith asserting a moral obligation to do so.Yet Oklahoma law requires honoring a patients advance directive or else transferring the patient to a provider that will honor it. Initially, the attending doctors and St. John officials sought to transfer the woman to a nursing home where her request to forego a PEG tube would be honored. But her nephew vetoed that. Given that the nephews position was in line with the bishops, the hospital then tried to transfer the patient to a nursing home where a feeding tube would be installed. Sister Carol Keehan, executive director of the Catholic Health Association representing hospitals and other facilities, said the bishops point is you dont have the right to just stop feeding them because their life is a burden. But the new policy, in her view, would come into play infrequently, mainly in cases involving a persistent vegetative state. For that reason, said the CHA senior director for ethics, Ron Hamel, "There probably was not much publicizing" of the revised directive by Catholic facilities.There are more than 600 Catholic hospitals and hundreds of nursing homes and other facilities; the hospitals alone admit nearly six million patients a year. Keehan doesn't see much potential for conflict between patients and families end-of-life wishes and the new directive. Advance directives are held in great respect in Catholic hospitals, she said in a recent interview. Some might like to say theres a terrible problem, but there isnt.

Jimmy Mac 01/24/2012 - 3:12 pm subscriberThe nuns are gone; the Catholicism is gone.Do you actually believe that? Therefore there are no Catholic schools unless nuns run them. Therefore there are no Catholic nursing homes unless there are no nuns running them.What a narrow definition of what it is to be a Catholic anything.Therefore, there is no Catholic church because there are no nuns running it. (I can buy that one!)Jimmy Mac 01/24/2012 - 3:18 pm subscriberOops s/b: there are no Catholic nursing homes unless there are nuns running them.

Yep. The best face of Catholicism was the nuns in the schools, hospitals, and nursing homes. That kindness and charity is gone, replaced with a legalistic mentality and an almost angry drive for social justice, narrowly and jealously defined. An institution, like a person, is what it does.Ann, yes I know nuns - and like and respect them greatly. Of course, they're "liberal" - there are no large religious communities left - they can hope for help for the people about whom they care particularly only from the government. Very sad, I think.

Bruce,In that case, be absolutely sure who your proxy is, and specify successor proxies in case of incapacity or death of the original designee. It's the question of who gets to interpret what constitutes Catholic teaching in your particular case, and at a time of great stress. DNR's may be ignored; it may not always be possible to survive a transfer to another facility, and just having to haggle with a bishop like Slattery of his surrogates is a terrible burden. Who needs it? or hazards the chance?It's situations like this I want to avoid (source undetermined from someone posting here before; my file incomplete):"A woman died in 1992, aged 90. She was a resident of a Little Sisters of the Poor home. She had suffered a number of small strokes. She had expressed end-of-life directions quite clearly, including NO feeding tube.She had another small stroke and was taken to a Catholic hospital. They stabilized her, etc., and said she could be returned to the Little Sisters home. But they said she would have to have a feeding tube inserted. They told her daughter this. The daughter said NO feeding tube. They hospital staff told the daughter that without the feeding tube, the Little Sisters of the Poor would not take her mother back. They convinced the daughter of that. The daughter went back into her mothers room and explained that she had to have a feeding tube. She then went back out into the hall to call her family members and tell them the latest development. When she got off the phone and went back into the room, her mother was dead.Her daughter believes she died of fear/frustration/horror at being helpless in the hands of strangers determined to force feed her. As it turned out, of course, the Little Sisters had said nothing like that. It was simply the hospital staff who were determined to do what they wanted to do, regardless of the patients wishes. It didnt occur to the daughter to call the Little Sisters of the Poor and ask them if that was really their rule for their residents. She trusted the Catholic hospital staff."Ann O also spoke previously of having to battle a doctor who was as rigid as Slattery. I find such anecdotal evidence cautionary.

I also think it is false that non-Catholic health care is not respectful of or caring for patients and their families. I have had occasion to go as an accompanying family member to Beth Israel-Deaconness in Boston. I cannot speak highly enough of the nursing staff, or of the way they handled the concerns of anxious family members.

(Carolyn, I wrote that comment about my mother. Next month with be the 20th anniversary of her death. Thank you for saving it.)---- Advance directives are held in great respect in Catholic hospitals, vs. the use of feeding tubes "must be considered ordinary and appropriate and as such, morally obligatory. Who wins that argument, the nun or the pope?

David Smith is at it again: "the angry drive for social justice." Where did that semantic come from?The days of having many nuns in place to provide education, nursing, etc. is gone.The nuns of today have been "visited," a good legal canonical term, and their limited number carries on many wonderful things. They try to deal with present and furture realities, not nostalgia.From where I sit, there's far too much "it's about us" coming from USCCB and many others in Catholic corners trying to hang on to a credibility that's continually being lost - because 'it's about us."That credibility can only begin to be regained when the first priority is about others -service. David's right about one thing - legalism has replaced that so , to paraphrase Shakespeare, "the first thing we should do is kill all the (canon) lawyers."

I agree with Cathleen and Carolyn's comment on caution. At present, my wife and I are dealing with one case of lethal disease, although without the urgency of the instances mentioned above. We and the doctors involved have a choice of Catholic or non-Catholic hospital, both nearby and considered generally good. Statistics of care options are known to the doctors and us but apply only to a group. They do not tell what will happen with the individual. The possibility that some medically incompetent and irresponsible bishop like Olmsted is lurking in the background with influence over serious medical activity in one of these hospitals is a frightening prospect. The reactions to his thinking and action that we heard from 200 other bishops give little reason for comfort. The notion of telephoning around to investigate moral specifics of involved parties is theoretically useful but impractical with the complex of people and organizations involved. We trust the ethical and medical competence of the specific professionals with whom we are dealing and can do no better.

Gerelyn --I am so sorry about what happened to your mother. Poor lady. It wasn't right.That argument about "ordinary means" never ceases to amaze me. The principle that ordinary means should be used to care for the sick is beyond reproach. Anything less would be cruel. It's the definition of "ordinary" that is the problem. Given that the official theologians are so enamored of the concept of "natural" (as well they might be), it seems to me than "non-ordinary means" should be defined as "means not found in or not produced by nature". Water and food found in and produced by nature (e.g., water and fruit) would then be ordinary, while anything like hardware (the tubes and machines) are non-natural in the sense of the above definition, and, therefore, they would not be required. Ordinary stuff is what is found all around us. Tubes and specialized machines aren't.But even the offering of food and water can e iffy. When my mother was dying (at age 85 and somewhat senile), she refused to eat. Was she to be forced? There was no thought of that except by the rigid doctor. I should add that when her doctor insisted that tubes be used my father and I went to consult with the priest who taught medical ethics at our seminary here. (He is highly regarded -- even non-Catholics take his courses). He said of course she didn't have to have what she was refusing. It is very surprising to me how many people here have had bad experiences at Catholic hospitals. I think the laity in repressive dioceses should somehow make this an issue with the bishops == and the Vatican, of course. I suspect the Vatican is the problem, given its idolatry of JP II.

David S: "The best face of Catholicism was the nuns in the schools, hospitals, and nursing homes" is not the same as The nuns are gone; the Catholicism is gone.I am not for one minute denigrating the value and service of the thousands of nuns who had a great deal to do with making this church what it was. But if the existence of Catholicism is based on the existence or non-existence of any particular group (including clerics of all stripes, levels and magnitude) then it is doomed.I always thought that Catholicism survives because of its uniqueness of Eucharist, mission and ministry. Those essentials will exsit long after groups, stripes, levels and magnitudes come and go.

Thank you, Ann. The daughter in the story was my sister. I was the person she was calling. Our mother died without the last sacraments. ----------This is an interview with Jane Brody, NYT columnist. I've clipped some of her columns and included them in my end-of-life directives.

Gerelyn,I am deeply saddened to hear that was your mother. Thank you for your generosity in sharing the unconscionable experience. Such travesties of care deserve wide dissemination, so that families may be warned. This is very helpful as I update my directives. In fact, I was planning to attach some of your materials.Jane Brody's book is on my list. Again, thank you.

"I also think it is false that non-Catholic health care is not respectful of or caring for patients and their families."Cathleen, I agree.It makes me wonder just what it is about Catholic hospitals that are distinctive. It's difficult not to think about the question in terms of branding and marketing. And the trends that are driving Catholic health care systems to broaden their membership seem to be more about economics and finance than the moral/doctrinal hot button topics that we tend to kick around here.

Thank you, Carolyn. I'm going to order Jane Brody's book, too. ---------Agree, Jim, that it's about money. I'm sure everyone is aware of the financial success/clout/etc. of orders like the Sisters of Mercy. ----------Link to a summary of an article from Neurology Today: Notice the many conditional (weasel) words and phrases. Expecting patients and their relatives to engage in disputations with nurses and doctors, when none of the participants are theologians but some of them are in extremis, is cruel and crazy.

The unavoidable reality in many senses: No margin, no mission.

A post-announcement article from Kaiser Health News, similar to the one Cathleen started with, is at . Its closing comment from the director of a project which aims to protect reproductive services in religious-secular mergers is notable: "What we are seeing on the Catholic [hospital] side is a willingness to let the secular partner develop a way to keep the services intact."

I looked at the USCCB Ethical Directives (see excerpts below). They seem to be imprecise enough that you could get very different interpretations of what they require depending on who you ask for advice. If you get an interpretation that seems unreasonable to you I would consult other knowledgeable people to see if they all agree. The closing paragraph indicates that these directives are recommended by the USCCB for implementation by the diocesan bishop, so their application is left to each bishop to decide."We have a duty to preserve our life and to use it for the glory of God, but the duty to preserve life is not absolute, for we may reject life-prolonging procedures that are insufficiently beneficial or excessively burdensome. Suicide and euthanasia are never morally acceptable options....The use of life- sustaining technology is judged in light of the Christian meaning of life, suffering, and death. In this way two extremes are avoided: on the one hand, an insistence on useless or burdensome technology even when a patient may legitimately wish to forgo it and, on the other hand, the withdrawal of technology with the intention of causing death.The Churchs teaching authority has addressed the moral issues concerning medically assisted nutrition and hydration. We are guided on this issue by Catholic teaching against euthanasia, which 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. While medically assisted nutrition and hydration are not morally obligatory in certain cases, these forms of basic care should in principle be provided to all patients who need them, including patients diagnosed as being in a persistent vegetative state (PVS), because even the most severely debilitated and helpless patient retains the full dignity of a human person and must receive ordinary and proportionate care.56. A person has a moral obligation to use ordinary or proportionate means of preserving his or her life. Proportionate means are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community.57. A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patients judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.58. In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic and presumably irreversible conditions (e.g., the persistent vegetative state) who can reasonably be expected to live indefinitely if given such care. Medically assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be excessively burdensome for the patient or [would] cause significant physical discomfort, for example resulting from complications in the use of the means employed. For instance, as a patient draws close to inevitable death from an underlying progressive and fatal condition, certain measures to provide nutrition and hydration may become excessively burdensome and therefore not obligatory in light of their very limited ability to prolong life or provide comfort.59. The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life-sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching.60. Euthanasia is an action or omission that of itself or by intention causes death in order to alleviate suffering. Catholic health care institutions may never condone or participate in euthanasia or assisted suicide in any way. Dying patients who request euthanasia should receive loving care, psychological and spiritual support, and appropriate remedies for pain and other symptoms so that they can live with dignity until the time of natural death....This fifth edition of the Ethical and Religious Directives for Catholic Health Care Services was developed by the Committee on Doctrine of the United States Conference of Catholic Bishops (USCCB) and approved as the national code by the full body of the USCCB at its November 2009 General Meeting. This edition of the Directives, which replaces all previous editions, is recommended for implementation by the diocesan bishop and is authorized for publication by the undersigned."

John Hayes --Yes, these directions are not clear at all, and one of them is plain silly when you look at it closely. Consider: " the withdrawal of technology with the intention of causing death. . ." Withdrawal of help doesn't *cause* death -- it lets it happen. I'm not defending euthanasia, but let's be very careful not to say someone killed someone else because he or she did NOT do something. This silliness is repeated in "euthanasia, which is an action or an omission which of itself or by intention causes death. . ." I can intend to kill my neighbor all I want but he won't die of it. Yes, my intention is evil, but I didn't kill him. Such loose talk muddies the ethical waters.In fact, given the bishops' own exceptions, in some cases one may ethically withdraw help and not thereby "kill" the sick person at all. Then consider: "even the most severely debilitated and helpless patient retains the full dignity of a human person and must receive ordinary and proportionate care." It has been argued that we die in stages. Aquinas argues that just as there is a sequence of forms in a fetus develops into a human person, analogously when a person dies slowly, the human form (the soul) is lost first, then the animal one, then the vegetative on. (Amazing what you can get out of Thomas if you ignore what he says.) in fact, you can be brain dead and still breathe. The higher functions are lost, while the lower ones persist, and in some cases it is the electrical system of the heart which keeps the body going. Yes, the heart has an electrical system of its own which can function without the brain.\

Tonight, I found that the Archdiocese of Boston publishes an "approved" Health Care Proxy form, giving the instructions you want carried out by your proxy:I direct that my Agent make Health Care decisions for me which are consistent with authentic Roman Catholic ethical, moral and religious principles and based upon my profound respect for life and my belief in eternal life. I direct my Attending Physician(s) and the Facility where I am a patient, provide me with proper medical treatment and care including, but not limited to:(a) appropriate pain relieving medicine in an amount to alleviate or suppress my pain, but not calculated specifically to cause or hasten my death;(b) food and water to sustain my life, including when provided by artificial means, and including when I am diagnosed as having a chronic and presumably irreversible disabling condition(sometimes described as a persistent vegetative state)and I am reasonably expected to live if given food and water; however, my Health Care Agent may consent to discontinuing food and water when they no longer provide reasonable hope of prolonging my life or relieving my suffering, or they may be discontinued when their provision or the means of providing them causes me significant discomfort or imposes other excessive burdens on me or my family(c) standard comfort care appropriate for any patient suffering from illness, injury or disease; and(d) [if I am pregnant] treatment or care necessary to benefit my unborn child, even if such treatment or care shortens or prolongs my life when I am diagnosed as having a terminal condition(e) _______________________________ (Please list other wishes here)__________

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