The National Catholic Review
'Medically ordinary' does not always mean morally ordinary.
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If I’m ever in a situation where I’m permanently unconscious and unable to eat,” says my father, “I’m begging you: Let me go. I don’t want to be kept alive by a feeding tube.” We are sitting at my parents’ table on a pleasant Sunday morning, with advance health care directives sharing space with coffee cups and the newspaper.

I probe my father’s reasoning about such an important decision: “What if I think you’re able to recognize us, but you are unable to speak, communicate or engage us? What about end-stage Alzheimer’s or Parkinson’s, where you might stop eating on your own? You both know that doctors are rather certain that patients in a persistent vegetative state don’t experience pain or discomfort, right?”

No response.

“What if I want to keep you alive in that condition?” I ask with a smile.

My father responds with a chuckle. “If there were a decent chance that I’d get better and everything else is working well, then I’d trust your judgment,” he tells me. “Otherwise, the answer is no. Let me go!”

“But why,” I ask, “if you’re unaware of your own condition?”

“Because I know now that I don’t want to continue like that. What am I continuing for? With whom could I communicate? Whom could I love? Would I not have somewhere better to be, anyway?” My father’s quip reflects our shared faith in Christ’s salvific death and resurrection. “Let me go.”

Real people bear both the grace and the burden of thinking as the church does about the meaning of living and dying. So it is with my still-living father’s words in mind that I think about a recent statement of the Congregation for the Doctrine of the Faith concerning the morality of removing artificial nutrition and hydration from a patient who lives in a persistent vegetative state. I have my parents’ power of attorney for health care, a decision they made prompted by the publicity surrounding the Terri Schiavo case. I now have a more personal stake in a discussion that had already engaged me professionally, as a Catholic bioethicist teaching in a Catholic medical school. It is now my responsibility as a son who cherishes his parents to help ensure that the manner of their dying as Catholics will be consistent with the way they lived as Catholics.

The U.S. Bishops’ Questions

In March 2004, Pope John Paul II gave an address in which he spoke about artificial nutrition and hydration for patients in a “vegetative state.” He wrote that artificial nutrition and hydration “always represents a natural means of preserving life, not a medical act.” Nutrition and hydration, then, should “be considered, in principle, ordinary and proportionate” means if they achieve their “proper finality”—in this case, providing nourishment to the patient.

That papal statement set off a wave of reaction from the press, the public and the faithful. Many wondered how the Holy See could hold that the surgical insertion of a feeding tube through the abdominal wall did not constitute a “medical act.” Others wondered how the removal of assisted nutrition and hydration in patients in a persistent vegetative state could be an act of “euthanasia by omission” if the intention of the act was to remove an excessively burdensome treatment rather than to kill the patient. Still others questioned whether the description of persistent vegetative state as a “stable” condition was a fair description of a patient who without medical intervention would surely have died from a devastating brain injury that had permanently eliminated the patient’s ability to eat and swallow with conscious purpose.

Seeking clarification of the allocution, the U.S. Conference of Catholic Bishops sent a letter on July 11, 2005, to the Congregation for the Doctrine of the Faith, with the following 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?

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?

The bishops’ questions raise three possible exceptions to the general rule that artificial nutrition and hydration for the patient in a persistent vegetative state constitutes ordinary care: first, when artificial nutrition and hydration cannot be assimilated by the patient; second, when artificial nutrition and hydration might cause “significant physical discomfort” to the patient; and third, when there is no hope that the patient will recover consciousness.

The Congregation’s Response and Commentary

The congregation answered the questions on Sept. 15, 2007, in a document entitled Responses to Certain Questions of the U.S. Conference of Catholic Bishops Concerning Artificial Nutrition and Hydration. The response to both questions maintains that in principle artificial nutrition and hydration constitutes ordinary care for these patients in all circumstances. In the accompanying commentary, however, the C.D.F. calls attention to the phrase “in principle,” present in the original papal allocution, which allows for possible exceptions to a general rule.

The doctrinal congregation then identifies four such exceptions: first, when remote geography and/or extreme poverty make the administration of artificial nutrition and hydration impossible; second, when “emerging complications” prohibit the assimilation of artificial nutrition and hydration; third, when, “in some rare cases,” it “may be excessively burdensome;” and fourth, when, “in some rare cases,” it “may cause significant physical discomfort.”

In exploring the significance of these exceptions, we must recognize that the document is restricted to a discussion of patients in a persistent vegetative state, a diagnosis that affects only a miniscule number of patients. We must also recognize that a growing popular acceptance of outright euthanasia influenced the congregation’s thinking.

‘Medically’ Versus ‘Morally’ Ordinary

The U.S. bishops sought to establish the boundaries within which artificial nutrition and hydration for patients in a permanent vegetative state must be judged morally obligatory. But the presupposition of their questions seems curious in the light of Catholic moral tradition, which has always recognized that a significant difference could exist, in a particular case, between that which is medically ordinary versus that which is morally ordinary.

Procedures that are medically ordinary, in the sense that they are readily available, technically feasible and of biological benefit to the patient, are not always morally required. This important distinction can be found in a document issued by the Diocese of Richmond, Va., that was intended to help patients and families think about their health care decisions:

What the medical profession might consider as “medically ordinary” is not necessarily the same as what the Church states is “morally ordinary.” Doctors might consider a particular procedure “ordinary” because they practice it frequently and expertly. Yet you cannot consider any medical procedure to be always morally ordinary no matter how routinely it is practiced.

The focus of the U.S. bishops’ questions and the C.D.F.’s response is the objective, medical feasibility of a particular procedure. Yet this limited perspective does not take into account in any explicit and satisfying way the patient’s and the patient’s family’s subjective and prudent judgment of whether such a procedure in their particular circumstances is morally ordinary and therefore obligatory.

Quoting from John Paul II’s papal allocution of 2004, the C.D.F. ties the determination of what is morally ordinary to an objective judgment of its medical efficacy: “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 most cases, a patient’s body can assimilate the nourishment that is administered, so that the use of artificial nutrition and hydration can be considered a medically ordinary procedure. But after considering the question of technical efficacy, must one judge this procedure to be morally ordinary when a patient or a patient’s proxy has judged the intervention to be excessively burdensome?

The Patient’s Judgment

The Ethical and Religious Directives for Catholic Health Care Services offers further clarification on this important distinction. Directives 56 and 57 state that the determination of what constitutes morally ordinary or extraordinary care should be based on “the patient’s judgment” of the benefits and burdens of a particular treatment. Directive 58 designates that “[t]here should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration as long as this is of sufficient benefit to outweigh the burdens involved for the patient.” It is the phrase “in the patient’s judgment” and the accompanying prudential consideration of burdens and benefits that preserves the distinction between what is medically ordinary and what is morally ordinary. Were this not the case, we would leave all health care decisions to the discretion of competent physicians, who could judge what is medically ordinary in terms of technical efficacy.

In addition to citing the criterion of assimilation, the congregation offers three more objective criteria that could justify exceptions to the general rule: first, when there exist medical problems associated with the administration of artificial nutrition and hydration (the possibility of infection or aspiration, for example); second, when a remote geographical location may preclude access to the technology; and third, when extreme poverty makes the procedure prohibitively expensive. But what would be a moral judgment of these objective circumstances?

Such circumstancs include where one lives, what financial resources are available and what medical complications are likely to arise from the procedure. If the congregation intends to restrict the possible exceptions to its general principle to those cases where objective circumstances make the procedure practically impossible, then there would be no need for directives 56, 57 or 58 or, for that matter, any moral reflection at all.

Such an interpretation, however, runs counter to the experience of patients familiar with the procedure, patients whose consciences are informed by their lifelong Catholic faith. My father, in our conversation at the kitchen table, for example, did not suggest any inclination to end his life prematurely. He does not seek a false sense of control over his dying that betrays the truth of our Christian narrative, namely, that suffering is constitutive of who we are as brothers and sisters of Christ and that the experience of dying, while possibly frightening and lonely, is ultimately identified with Christ’s dying and redeemed in Christ’s rising. But his judgment, informed by his faith, is that a massive neurological injury that leaves him permanently unconscious, unable to purposefully eat or swallow, would constitute in itself a fatal pathology, one that carries no obligation to persist any longer in that state.

When I consider my father’s questions—“What am I persisting for? With whom could I communicate? Who could I love? Don’t I have a better place to be?”—I hear faithful echoes of our Catholic tradition. That tradition consistently affirms that while biological life is an important value, it is not an absolute good. How should my father judge a future burden that is not his now and, were it ever to become his burden, he would not be able to judge?

Perhaps it is in the fourth exception noted by the C.D.F. that my father’s thinking finds its voice. While the other three exceptions offered by the congregation focus on objective circumstances, this final exception simply notes those “rare cases” where artificial nutrition and hydration “may be excessively burdensome.” This exception stands out because it comes with no modification. It simply holds open a possibility. While the C.D.F. does not offer any examples, it sounds to me like the condition my father described over our kitchen table.

My father’s words tell me that he judged the maintenance of his baseline biological existence as a P.V.S. patient to be an excessive burden. It is a burden to him to know now that we, his family, would care for him in this condition for a prolonged period of time. It is a burden to him to know that he would be unable to engage in meaningful human activity. And, finally, it is a burden to him to think that his death from a devastating neurological injury was being held at bay by the insertion of an unwanted and, in his judgment, invasive feeding tube. My father believes that such a procedure would pose an unwanted and unnecessary obstacle to his next life in heaven, the end of a journey he began at birth, the fulfillment of a promise sealed in his baptism.

In other words, my father has judged that the burden of persisting in a vegetative state far outweighs the benefit of being sustained that way. This is, in my view, a very Catholic way of thinking, shared by other faithful Catholics, and consistent with Catholic tradition.

John J. Hardt is an assistant professor of bioethics at the Neiswanger Institute for Bioethics and Health Policy at Loyola University Chicago's Stritch School of Medicine.

Comments

ANDY GALLIGAN | 1/23/2008 - 5:49pm
As over many issues it's apparent from the above comments that there is no universal agreement on this issue by intelligent Catholics. I find that acceptable, considering that there is no infallible pronouncement on this moral situation. Both sides have their reasons, their arguments. What would be wrong with using the old teaching of Probablism and allowing the individual to choose in good conscience the opinion that he/she sees as consistent with Catholic principles? One may choose the stricter opinion for oneself, but I should think it would be wrong to force that on some other person. Catholic theology has long held that we do not have to use "extraordinary" means and that is to be determined primarily by judging whether the perceived burdens of a procedure outweigh its perceived benefits. We also know that life is not an absolute good, and I agree with those who say that indefinitely keeping a PVS patient alive is really a form of physicalism/vitalism, not a defense of human life. Too bad that the Jesuit theologian Richard McCormick is not still alive to help those who would listen handle this problem in a reasonable fashion.
David Pasinski | 1/17/2008 - 7:55am
It is fascinating to read our range of comments. However, I am struck by some fellow contributors notions about the role of suffering, the speculation about these mysterious mental states, and the always debatable "will of God." Also, there seems to be operating for some a kind of "technological imperative" -- if it can be done, it must be done -- which is repudiateed in other spheres. I had the opportunity to read and listen to one of the true medical experts in this complex field of minimal conciousness and brain activity, Dr. Joseph Fins, and believe that all of us, regardless of medical background, would understand and benefit in reading his work as we opine about the human condition in these states, their "meaning," and what our responsibilities are.
Judy Hake | 1/16/2008 - 1:42pm
What bothers me about the whole idea of advance directives is that we really have no idea what we are going to want if we find ourselves in circumstances where we are helpless to express our wishes. We do not know enough about persistent vegetative states or comas or similar conditions to know what is going on in the mind, heart, or spirit of the afflicted person. The person in a PVS state may well be liberated from human restraints and communicating with God in ways that are unavailable to the rest of us. We hear story after story of someone who was in a coma but aware of things going on externally. Plus, making an end-of-life decision like this presupposes that miracles never happen. If we truly believe in a loving, merciful, all-powerful God, would we not also believe that our life is totally in His hands, even on the matter of when we die? If it is not His will for us to live, will medical intervention keep us alive anyway? Could He not take us in spite of it? The whole idea that we might decide such things ahead of time, or that we might think that artificial feedings would keep us from heaven when it is our time to go, puts too much control of our lives back in our own hands, in my opinion. Are we going to surrender our entire lives to God, or not? Assuming our lives truly belong to God, surely no human in this world can either take or prolong life without His permission. It is so easy for people to say, "I know I would never want to be kept alive like that." But we truly do not know what we would want in such a situation. Why not leave the decision up to God?
9820515 | 1/16/2008 - 12:15pm
I read this article with great interest because 3 years ago I was faced with this situation. My mother went into surgery and lapsed into a coma afterwards. The doctors told us that her brain stem was damaged and that she probably would never recover. My father pushed for us, my brother, me, and my mom's sister, to take my mother off of life support. In a state of fear and uncertainty I unwillingly said yes. My mother was only on life-support for a day. The doctors told us that it would only take 45 minutes for my mother to pass on; it took a week. For 7 days I watched my mother slowly die. Every minute of those 7 days was hell. I still am haunted by the moment my mother died. The knowing that I said "yes" to have my mother die is unbearable. Knowing and living with what I did feels like a sin that I commit every day.
Letha C. Chamberlain | 1/15/2008 - 1:05pm
Being a health care consumer who has used over $2 million in health care dollars already--and am only 59 yrs old with 3 potential life-threatening diagonses, but who is still a productive member of society... and being fervently Catholic I made some healthcare decisions that were problematic for my hospital chaplain spiritual-mentor, yet guided by my priest-confessor. I am well-aware of difficulties in interpretation of these various ethical guidelines, ho matter how clear they are attempted to be spelled-out. It boils down to what is between God and oneself--and carefully discerned in prayer with a good conscience and good information provided by Mother Church and one's doctor. Then one has to carefully provide oneself with someone whom one trusts to carry out those wishes--because there is sure to be emotional processes interfering with such delicate matters. Making these decisions public opens one to comment--so be prepared for the comments if you do that... otherwise, keep it between you and the person you have honored with your decisions!
James Ruzicka | 1/15/2008 - 12:19pm
This is just a test's. Testing special characters^ to see if its cutting off the comments*'swaef fhawef's posted.
mary santapaula | 1/14/2008 - 3:02pm
Thank you for writing this valuable article.
Marie Rehbein | 1/14/2008 - 1:23pm
No one seems to suggest praying as an option in the circumstance of someone being beyond the help of modern medicine. It is not necessary to pray for a patient's recovery. It is possible to pray for God to take the patient while the patient's body is being sustained using technology developed for that purpose. Those who try it should prepare themselves to be amazed.
MARIAN GRAY | 1/12/2008 - 3:54pm
This has been refuted before and is instructive. i quote, " In 2004, Pope John Paul II told an international medical-moral congress that "the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory." In 2005, the U.S. Bishops sent two follow-up questions on the statement asking for clarification on the statement. The questions asked for confirmation that the administration of food and water was morally obligatory and if food and water could be removed in the event of a doctor's judgment that the patient will not regain consciousness. The CDF responded in September of 2007 with a yes to the first question and a no to the second. Matt Bowman, a Legal Counsel for the Alliance Defense Fund, and graduate of the Ave Maria School of Law, summarized the errors of Hardt and O'Rourke on his blog (http://www.constitutionallycorrect.com/archive/2007/12/20/584.aspx)."
ROBERT ROWDEN | 1/12/2008 - 2:57pm
Many thanks to Professor Hardt for his clear and persuasive defense of traditional Catholic moral teaching. It is important for us pew people to understand the difference between what is medically ordinary and what may be morally exraordinary.. It is critical that we discuss with family our perceptions of what is excessively burdonsome, and to clearly state those perceptions in a directive to physicians.
ELEANOR LUNN | 1/12/2008 - 2:37pm
After reading the legalese in this article and the hair splitting, I am instructing my daughters to never admit me to a Catholic hospital. I would die from the agita caused by the wrangling and hand wringing. The people in Rome are still arguing about how many angels fit on the top of a pin. I will use my common sense and my 16 years of Catholic education to help me decide what medical means will be used at the end and believe me it will be a moral decision.
Basil De Pinto | 1/12/2008 - 1:18pm
As a retired hospital chaplain I welcome the sound reasoning and informed compassion of this piece. It expresses what I have always considered the Catholic teaching on care of the sick, and which I have used myself as the basis of assistance to patients and families when they were faced with difficult, end of life decisions. I will certainly recommend Professor Hardt's article and pass it along to as many interested parties as I can.
ROBERT KILLOREN | 1/12/2008 - 1:11pm
I hate to follow the comments of anyone named Novak for fear of tangling with the razor sharp intellect of Michael (I mean that as a compliment), but I still would like to share some of my thoughts. In my pastoral care, I have encountered this issue more times than I would wish. I have seen grave concern and sometimes trauma that families deal with when faced with this ultimate dilemma – they truly fear making a decision either way - even when the decision to "pull the plug" is much clearer than when one is dealing with the matter of artificial nutrition and hydration. It is hard as well not to engage in agonizing second guessing and regrets either way they decide. The same is true for those of us who have to respond to a family's plea for guidance and answers. Did I advise them as Christ would? It is good for us to read what the moral theologians say and the Church teaches in those extraordinary documents mentioned in the article, but in the real world, it seems to me, one leaves the theoretical plane and enters the realm of conscience. True, the individual conscience must be properly formed, but the fact that the Church is still struggling itself to better understand this particular issue suggests the difficulty of arriving at moral certainty, so how "properly formed" can a conscience be? I appreciated particularly Professor Hardt's statement that his father's motivation in wishing not to be artificially fed or hydrated under certain circumstances was not to prematurely end his life or take false control over it in a way counter to Christ's teaching and example. It was motivated by a desire to let a natural death take him to God. Novak mentions Jesus' suffering on the cross (and by the way Professor Hardt did mention Jesus' death, but it was clearly linked to the resurrection into new life) as an example of redemptive suffering. In the synoptic Gospels it appears that when offered a drink on the cross Jesus refused it and then it says he gave up his spirit. Would it be wrong to let someone give up their spirit? Pastorally, I have the most trouble with those who are suffering from end stage Alzheimer's. If they stop eating and drinking when food and water is offered can they be allowed to let go? And I agree with Novak that we are body and spirit, but what is the spirit worried about in the case of being in a persistent vegetative state? Is it concerned about water that does not give life or is it concerned about receiving living water and never thirsting again?
David Pasinski | 1/12/2008 - 12:08pm
Thank you for beginning and grounding this discussion in a real discussion with your father --similar to my own conversation with my 89 year old father. I have 14 years as a health care chaplain with advanced degrees and ethics specialty and have read extensively on this issue and appreciated Dan Sulmasy's recent commentary in Commonweal as well as the the new book (before CDF pronouncement) from Georgetown Press on the Catholic positions (plural) on this issue. My fear however, in your citation of this as justified by the CDF as "rare case" is that it is not that rare. It is really a rather common and common sense approach that you and other faithful teachers are being forced to shoehorn into a category to make it conform with an ill considered and, I believe, questionably historically grounded pronouncement. I understand the context of the CDF statement and the ongoing issues that the sad Schiavo case raised and believe that the most helpful role that any of us involved in health care ethics can have is the promotion of the discussion of advance directives and health care proxies -- as you did with your father. Thank you for modeling that and for providing a space for common sense. Let's hope that such discussion and common good judgment by your father-- and hopefully your own full-hearted compliance as his proxy -- will be a model in spite of the tone of CDF document rather than simply a case example of its begrudging "rare case."
David Pasinski | 1/12/2008 - 12:07pm
Thank you for beginning and grounding this discussion in a real discussion with your father --similar to my own conversation with my 89 year old father. I have 14 years as a health care chaplain with advanced degrees and ethics specialty and have read extensively on this issue and appreciated Dan Sulmasy's recent commentary in Commonweal as well as the the new book (before CDF pronouncement) from Georgetown Press on the Catholic positions (plural) on this issue. My fear however, in your citation of this as justified by the CDF as
LEONARD VILLA | 1/11/2008 - 7:00pm
The Cross and union with the Passion of Christ is never mentioned in this essay. Surely this is part of Catholic thinking on catastrophic illness. Secondly the ordinary/extraordinary calculus is made with respect to the actual medical condition of the patient not some imagined condition as in living will clauses. Third there are enough cases to indicate that the awareness of the person with severe brain injuries is greater than doctors indicate when they call them "vegetables" because they are working simply from a material paradigm. Catholic teaching indicates that reality is larger than the material because human beings are composed of body and soul.