It has long been the teaching of the Catholic Church that taking extraordinary measures to prolong life in the case of serious illness is not morally obligatory. Where such measures are judged by the patient or proxies to be futile or excessively burdensome, they can be stopped. A recent statement by the Congregation for the Doctrine of the Faith (CDF) concerning the morality of removing feeding tubes from patients in a persistent vegetative state (PVS) has thrown that teaching into question.
The statement, in fact, appears to contradict the traditional criteria used to determine whether a particular medical treatment is ordinary and proportionate and therefore obligatory, or extraordinary and disproportionate and therefore optional. Caregivers for someone like Terri Schiavo—kept alive for fifteen years in PVS despite having suffered massive and irreversible brain damage—are now being told that removing her feeding tubes amounted to euthanasia. Equally problematic, under the CDF’s new ruling Catholics may no longer leave an advanced directive stipulating that they do not want to be kept alive indefinitely in PVS.
When to discontinue a medical treatment thought futile or unnecessarily burdensome is a torturous decision, one that Catholic tradition has long approached in a casuistic and nuanced way. As Daniel P. Sulmasy, OFM, writes in this issue (“Preserving Life?”), even though the CDF statement is narrowly drawn, a danger exists that Catholics will now think that removing feeding tubes is prohibited in all circumstances. But that is not the case. Patients facing imminent death may still forgo such treatments. Whether patients who are incapable of feeding themselves and will never regain consciousness can be said to be dying is part of the moral conundrum surrounding PVS.
As Sulmasy points out, perhaps the best way to understand the CDF’s action is to see it as part of the Vatican’s strenuous efforts to resist the legalization of euthanasia in Europe—“an extreme position to counter extreme positions.” Unfortunately, the CDF statement goes too far, and seems nearly impossible to reconcile with the church’s otherwise sophisticated and widely respected contributions to how to think about end-of-life decisions in a world where medical technology, rather than morality, increasingly dictates what is done. Historically, the church’s teaching has been patient-centered and flexible enough to allow the sick and the dying (and those caring for them) to weigh many factors in determining whether a treatment is obligatory or not. Preserving physical life has never been regarded as an absolute value. Traditionally, a cost-benefit analysis played a role in the decision. No family is obligated to bankrupt itself to prolong the life of a dying relative. The CDF statement, however, comes close to arguing that such an analysis is no longer permitted for PVS patients in relatively prosperous countries. Equally disputable is the statement’s assertion that feeding tubes, which must be inserted and maintained by medical professionals, are to be regarded as “ordinary” care rather than medical treatment.
As Sulmasy notes, most people’s reaction to the prospect of being kept alive in a condition like Terri Schiavo’s is one of horror. That moral instinct has long been recognized in Catholic teaching, as has the distinction between removing feeding tubes from someone in PVS, thus allowing him to die, and intending his death.
It is hard to imagine a step that could discredit the church’s opposition to euthanasia more than Rome’s insistence that those afflicted with PVS are essentially condemned to spend the last ten, fifteen, or twenty years of their lives—even against their own wishes—in such a condition. Some may consider this a call for moral heroism on the part of PVS patients, their families, and the wider community, but the church has never taught that heroism is morally obligatory.
Cardinal Newman, commenting on the dangers of ultramontane Catholicism, and especially on demands that Rome settle all disputed questions as quickly as possible, urged patience from his fellow Catholics and intellectual modesty from the curia. Appealing to Rome should be a last resort. “So difficult is it to assent inwardly to propositions, verified to us neither by reason nor experience,” Newman wrote, “...that [the church] has ever shown the utmost care to contract, as far as possible, the range of truths and the sense of propositions, of which she demands this absolute reception.” Newman’s concerns were about dogmatic propositions of faith, but similar concerns are increasingly felt regarding the church’s pronouncements on moral questions. Utmost care must be taken there as well.