The National Catholic Review
Caring for patients in a persistent vegetative state
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In September 2007 the Congregation for the Doctrine of the Faith issued a Response approved by Pope Benedict to answer two questions posed by the U.S. Conference of Catholic Bishops on our moral obligations to patients who exist in what has come to be called a “persistent vegetative state.” The Congregation’s Response and its accompanying Commentary confirm and explain the statements made by Pope John Paul II on March 20, 2004, on the moral obligation to provide food and fluids to P.V.S. patients when they need such assistance to survive.

Two recent articles in America, “On Church Teaching and My Father’s Choice,” by John J. Hardt (1/21), and “At the End of Life,” by Thomas A. Shannon (2/18), appear to misunderstand and subsequently misrepresent the substance of church teaching on these difficult but important ethical questions.

The Duty to Provide Basic Care

Thomas Shannon, in his article, cites the Declaration on Euthanasia of 1980, which spoke of the discretion patients may have to refuse medical treatment that seems to them burdensome, and therefore “extraordinary” or disproportionate. He argues that this judgment by a patient is distinct from a physician’s judgment that a treatment is “medically ordinary” in the sense of being customary or usual. What is “medically ordinary” can be “morally extraordinary.” This is a valid distinction, but there is an aspect of patient care even more basic than the distinction between ordinary and extraordinary medical treatments: the “ordinary care” owed to sick persons because of their human dignity, which the Declaration said should be provided even when certain medical interventions have been withdrawn as useless or overly burdensome. Pope John Paul II and his successor held that food and water, even when their provision may require technical medical assistance, constitute the “basic care” that patients should receive. The value of such medical assistance is not to be judged by its efficacy in curing the patient or improving the patient’s condition. Supplying the basic necessities of life can often require the assistance of others, in the case, for example, of those who are very young or very old, or simply very weak at any age.

In the case of medically stable patients in a “vegetative state,” who may live a long time with continued nourishment but will certainly die of dehydration or starvation without it, the obligation to care for our fellow human beings presents a very direct challenge. Such a patient’s condition should not be characterized as “unstable” or terminal simply because it would become so if the patient were deprived of food and water.

Limits to This Obligation

It is true that this obligation to provide basic care can be exhausted when such assistance can no longer fulfill its basic purpose or finality. The U.S. bishops asked the C.D.F. whether food and fluids should be provided “except when they cannot be assimilated by the patient’s body or cannot be administered to the patient without causing significant physical discomfort,” and the congregation’s response recognized the legitimacy of this exception.

When patients are dying and their bodily systems are shutting down at the end of life, medically assisted nourishment can be ineffective and even create additional suffering. This is why physicians did not initiate tube-feeding for Pope John Paul II himself when he was in his final days. The pope’s condition in his final hours was in no way comparable to that of a P.V.S. patient, who can live a long time with assisted feeding.

Thomas Shannon, in his article, confuses the three exceptions recognized in the congregation’s Response and Commentary, and John Hardt finds four such exceptions. The C.D.F. Commentary does speak of a situation where the obligation to provide nutrition and hydration does not apply. This is not really an exception to the norm, but rather the simple recognition that we are never obliged to try to do the impossible. Some parts of the world may be so destitute or undeveloped that they lack the medical resources and skills for the kind of assisted feeding that can occasion difficult moral decisions. John Hardt goes further when he suggests that the C.D.F. Commentary introduces a broader and more subjective category of “burden” that justifies a simple dislike for survival in a helpless state. But that claim has no foundation in the text, is actually contradicted by the Response and raises an additional problem that is discussed below.

The Teaching on Euthanasia by Omission

Both Hardt and Shannon acknowledge that a concern about euthanasia is part of the background for the C.D.F.’s Response. However, neither cites the longstanding church teaching that an omission of basic care may itself be euthanasia. Euthanasia is defined in the Declaration of 1980 as “an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated.” Such euthanasia is always morally wrong.

Here the church insists on the important distinction between validly withdrawing a life-sustaining means because the means itself is burdensome, and wrongly withdrawing it because (in someone’s view) life itself has become burdensome and should be brought to an end.

To cite this distinction in no way dismisses or minimizes the real suffering of long-term illness, or the real costs and burdens that families may undergo in caring for a helpless family member diagnosed as being in a persistent vegetative state. In his March 2004 Address to the Participants in the International Congress on Life-Sustaining Treatments and the Vegetative State: Scientific Advances and Ethical Dilemmas, John Paul II drew attention to this problem, insisting that such families “cannot be left alone with their heavy human, psychological and financial burden,” but must receive assistance from medical professionals, society and the church. This is the true meaning of “compassion” in the face of illness and disability, to “suffer with” the afflicted and lighten their burden through our support. The solution does not lie in seeking ways to hasten the patient’s death in order to lift burdens from the patient and family.

This is why the C.D.F. Response insists that assisted feeding may not be discontinued simply on the grounds that “competent physicians judge with moral certainty that the patient will never recover consciousness.” Even if one judges that such a condition, when prolonged, makes survival itself a burden, such a judgment does not justify removing food and water so the patient will not survive.

Some ethicists want to assess all the costs and burdens of caring for a helpless patient in a P.V.S., and then count these among the “burdens” of assisted feeding. One problem this approach raises is the question of intent. By omitting food and fluids, what are we trying to achieve? Whose “burden” are we trying to ease? Assisted feeding is often not difficult or costly to provide in itself, but the housing, nursing care and other basic needs of a helpless patient can be significant. To discontinue assisted feeding in order to be freed from such burdens puts the caregiver’s interests ahead of the patient’s, even if we prefer not to recognize the reality of our choice.

The Unity of the Living Human Person

Finally, the claim is sometimes made that the life of a P.V.S. patient, one who survives only because of medically assisted nourishment, is not a fully human life because it is not capable of interaction with other persons. Such a condition has been called a “baseline biological existence,” a merely “physical” life without inherent meaning or value. Assisted nutritional support, in this view, is warranted only if it may restore the patient’s ability to engage in the activities that constitute the value of our earthly existence. Such an argument has deeply disturbing implications, since it challenges the value of anyone with mental illness, retardation or cognitive disabilities who is not able to pursue what such critics deem “worthwhile” activity.

It was against such dehumanizing criticism that Pope John Paul II, in his 2004 address, insisted that “the intrinsic value and personal dignity of every human being does not change, no matter what the concrete circumstances of his or her life…. Even our brothers and sisters who find themselves in the clinical condition of a ‘vegetative state’ retain their human dignity in all its fullness. The loving gaze of God the Father continues to fall upon them, acknowledging them as his sons and daughters, especially in need of help.”

Our love and support for patients in P.V.S. should be modeled on God’s love, which is based not on their current ability to act and respond but on their enduring dignity as human beings, made in his image and likeness and facing an ultimate destiny with him. Earthly life is not the highest of all goods, and our hope in eternal life puts in proper perspective all disproportionate and burdensome efforts to sustain life.

Life is, however, the first and most basic good of the human person, the condition for all others: “Life is always a good” (Evangelium Vitae, No. 34). The way we treat this life here and now—especially the life of those who are most helpless and least able to care for themselves—has consequences for our own eternal destiny.

Persons in the so-called “vegetative state” deserve our unconditional respect. As Pope John Paul noted in his 2004 address, they should receive all reasonable assistance aimed at their recovery and rehabilitation. But even if such efforts at recovery do not succeed, we need to provide friendship and practical help to their families and treat these patients always as fellow human beings in need of basic care. In this way our Catholic community can build a culture of life that excludes no one from the circle of love and mutual support.

Cardinal Justin F. Rigali is the archbishop of Philadelphia and chairman of the Committee on Pro-Life Activities of the U.S. Conference of Catholic Bishops.

Comments

Sues Krebs | 11/25/2008 - 8:18am
How long do we prolong life after no hope of recovery is determined! Do we keep our loved ones alive because we are not ready to see them die or let God take them home when it's their time to leave? The only reason we keep them with us is selfishness and because we may not be ready.It is about the people who are leaft behind to live; not about our loved one on the verge of death.
Kenneth Smits | 9/4/2008 - 8:59pm
I write as a hospital chaplain, in the trenches, on the issue of human dignity and the end of life. I believe that the article of Rigali and Lori, and the teaching behind it, represents a shift to the right, as a reaction to the threat of euthanasia, and a loss of the balance and equilibrium I look for in the moral teaching of the church. Of course this is a discussion of principles; in practice every case has its unique circumstances in endless variety, and both principles and circumstances have value. Complexity is more the norm than the exception. Secondly, this teaching deals only with the rare occurrence of a "persistent vegetative state." In ordinary pastoral practice, this is all too easily interpreted (as I have heard from patients) as a general obligation to continue food and fluids in all cases. What is taught and how it is received are important corelatives. Thirdly, in accord with with principle of patient autonomy, widely recognized in health care, it is the patient and/or family/providers that make these difficult decisions. While doctors and chaplains advise, it is patient and family who decide, paying attention to written directives and vocal wishes of the patient. Fourthly, I live in a large apartment building of elderly people, most of them Christians. How often I have heard them say they don't want to be kept alive artificially. There is a certain common sense and wisdom in this stance that calls for our attention. I am blessed, from time to time, to be with an elderly hospital patient who has tired of the struggles of life, wants no more treatment, is ready to die, and looks forward to eternal life. This is where I find a balance which I do not perceive in the current teaching of the Church on human dignity and the end of life. Fifthly, it is nice to say that such families must receive assistance from medical professionals, society and the church, but until there are designated funds set up for such cases, this remains just a pious wish. Fr. Ken Smits
JOHN DAHMUS | 8/18/2008 - 7:49pm
The August 4 issue juxtaposes, perhaps inadvertently, two issues on health, MaryAnn Love's article on the plight of the sick poor and Cardinal Rigali and Bishop Lori's article on patients in a "persistent vegetative state." I wondered as I read both articles whether the two clergymen are sufficiently considering the needs of the entire community. Does, for example, care for the second group jeopardize care for the first? For there is only so much money to care for sick people. I am not suggesting that society should automatically eliminate certain groups,and Rigali and Lori are creating straw men when they bring up groups like the mentally ill as groups who would be eliminated next; this is not Nazi Germany. But does it make economic sense or Gospel sense to spend precious resources on people who will never recover? Even though Rigali and Lori deny that they believe that bodily life is the highest good, their argument seems to claim that it is. I am not a doctor, but is it possible also that these helpless people could give the gift of life to those waiting for organ transplants, some of whom will certainly die before they receive the necessary help. Pope John Paul II's request that the community rally in support of people dealing with PVS family members seems to me unrealistic. Rather it seems to me that the community has the obligation to care for the sick in the community who can really benefit from that help, and there are many, many of those people. In my opinion that is the meaning of Gospel charity.
Marie Rehbein | 8/18/2008 - 2:35pm
Stephen Barr's defense of authority in response to my objections to authoritarian pronouncements indicates a misunderstanding of my objection to the tone of Bishops Rigali and Lori. It is certainly wise to consider carefully the instruction presented by recognized authorities because of the likelihood of it's being well informed and thoughtful. However, telling people what to do without reference to the big picture and in opposition to their preferences, brings with it calls for ever more clarification as well as challenges based on other authorities. For example, Edmund F. Kal, M.D. offers the authority of St. Thomas Aquinas as counterpoint to the authority of Bishops Rigali and Lori. His understanding of St. Thomas Aquinas is premised on his acceptance of things once taught him by others in authority with respect to himself. Dr. Kal condenses Aquinas's substantial work to make the (possibly erroneous) point that purpose of the soul's embodiment is lost once the conscious brain ceases functioning. He uses this in support of his own opinion that when consciousness is not likely to be regained (in our judgment) we are no longer obligated to support the body of the disabled person. Michael Bindner, similarly, relies on different authority--even more detailed study of Catholic Doctrine--to make the callous judgment that the person who has been resuscitated can be deprived of food and water. Is it remotely possible that the resuscitation was successful because God willed it? Is it possible that God lets these people in PVS live for our benefit rather than theirs, particularly in the case of a resuscitated person? In this debate, we lose sight of our own souls--the place where our understanding resides, according to Aquinas. Bishops Rigali and Lori have told us that we do not have the judgment and authority to withhold nourshiment from someone whom we determine will not regain consciousness, but they failed to mention who does have that judgment and authority. What is the consequence to our own souls when we forget to go to that authority, but instead take it upon ourselves to make life and death decisions on behalf of others based on technicalities in Catholic Doctrine? We can and should pray to God: "God, take the unconscious person to yourself or give me the strength and resources to carry on, or deprive me of strength and resources so that I have an excuse for depriving the unconscious person. Amen."
Michael Bindner | 8/13/2008 - 7:07pm
Regarding the Lori and Rigali article, Euthanasia by ommission is equated with Passive Euthanasia, which when I was studying "Death and Dying" was considered permissible under Catholic doctrine. It is abject revisionism to state otherwise. Doctrine is not to be made by press release or by public address, which is essentially the standing that recent teachings on hydration and nutrition have. Finally, the circumstances of patients who have developed PVS over time are fundamentally different from those who have been resuscitated and have never regained conciousness. The former deserve continued care. The latter have already experienced "natural death" and should be allowed to return to it.
Edmund F. Kal, M.D. | 8/7/2008 - 9:58pm
With all due respect to Bishops Rigali and Lori, as well as to the authors they critique, it seems that amid all the discussion about ordinary vs. extraordinary, medical vs. nonmedical means, dignity of life etc., all miss the fundamental issue. "Life is always a good" they quote "Evangelium Vitae", but stop short of asking: Why? After all, in the Christian view everything that exists - in as much as it exists (i.e. is God's creation) - is "good", in fact "very good", as Genesis teaches. But many things are good not so much in themselves as means to other, higher goods; and even the latter only with a final reference to God, the Summum Bonum. So we can and should legitimately ask: What is the fundamental value, the purpose of human life on earth? If what I learned in 1st grade Catechism is still valid, it is: to get to know God, to love and to serve God,and thus to merit eternal life with God in heaven. Now, as St. Thomas Aquinas profusely and clearly teaches in his SUMMA (part I., questions 75-89), the human soul is a subsistent spiritual entity which, however, while united to its body (as the body's "form") during life on this earth cannot perform even its purely spiritual activities without the functioning bodily brain presenting to the spirit the "raw materials" to work on. In practical terms this means that a person in what is called a "permanent vegetative state" can no longer think nor love, neither sin nor merit further rewards for eternal life. Maintaining the purely vegetative functions of metabolism is of no further benefit to such a person. --- The argument that artificial nutrition and hydration are not "medical" interventions aimed at a "cure" but merely "basic ordinary care" would be correct only if one were to ignore that the metabolic function is a "good" precisely as a means to spiritual functions, meant to pursue the basic value of human life, as specified by the Catechism as quoted above. If such activities have become irremediably impossible, then nutrition and hydration lose their purpose, their "basic finality,"just as surely as when the body is no longer able to digest or absorb food or water. To stop administering food and water in such circumstances is not a disregard for the person's human dignity, it is not meant to shorten the person's life for whatever motives: it is simply an acceptance of the fact that any further positive efforts solely to prolong mere metabolic functions are, humanly speaking, of no further benefit to that person, and hence are no longer reasonable. To equate such cessation of efforts with "euthanasia by omission" is a misnomer; it puts an unjustifiable burden on those with tender consciences, and provides further ammunition for sarcasm to despisers of morality.
stephen barr | 8/7/2008 - 11:21am
Marie Rehbein makes some very insightful comments. However, it should be said (in response also to Andrew Galligan) that there is such a thing as legitimate authority. In all spheres of life there are people who exercize legitimate authority --- parents, legislators, judges, teachers, deans and provosts, military officers, and so on. The exercize of legitimate authority should not be branded as "authoritarian". There is very abudant evidence in the New Testament that Christ intended there to be people who exercize teaching authority in the Church, and that such authority was in fact exercized in the early Church. To take just one of very numerous examples, St. Paul tells his hearers that even should an angel from heaven contradict what he is teaching them, they are to listen to him (Paul) over that angel. Bishops Rigali and Lori are no more "authoritarian" in substance or tone than were the apostles whose successors they are. Dr. Rowden's entire comment is curious. He is far more authoritarian in tone than Bishops Lori and Rigali, with the important difference that he in fact has no legitimate doctrinal authority within the Church. He makes apodictic assertions about who has what rights and what obligations, based evidently on nothing but his own opinions. Bishops Rigali and Lori are arguing on the basis of a very long moral tradition involving carefully elaborated general principles that neither they nor Pope John Paul II nor Cardinal Ratzinger/Pope Benedict invented. Rigali and Lori are simply presenting traditional Catholic teaching in a clear way, making precise moral, logical, and terminological distinctions. They show, by a lucid analysis, that the two articles they are criticizing have failed to make certain necessary distinctions and have thereby misunderstood and misrepresented Catholic teaching. Far from simply laying down the law (which they would have every right to do), Rigali and Lori present arguments. The arguments are sometimes implicit, but they are there. Their essential argument is that provision of basic necessities like food and water is quite different in character from "medical" intervention designed to cure an ailment. Even a perfectly healthy person would die very quickly without water --- that in no way means that such a person is suffering from a "terminal" condition and that in being given water his life is being artificially prolonged by a medical treatment. That is the obvious point that undergirds all the other points Lori and Rigali make.
J STANGLE | 8/4/2008 - 6:20pm
I just have read in America magazine (August 4, 2008) the article “Human Dignity and the End of Life” by Cardinal Rigali and Bishop Lori. The authors respond to two recent America articles, “On Church Teaching and My Father’s Choice,” by John J. Hardt (1/21), and “At the End of Life,” by Thomas A. Shannon (2/18) on providing artificial nutrition and hydration to PVS patients. Shannon and Hardt, according to the article, "appear to misunderstand and subsequently misrepresent the substance of church teaching on these difficult and important ethical questions." It seems to me - as the title suggests - Cardinal Rigali and Bishop Lori touch a wider area of concern for human dignity, euthanasia, end-of-life and right-to-life issues. Their concern is not just the PVS patients’ situation but anybody who needs help for survival (little children, very weak, old or mentally ill persons for example): “Pope John Paul II and his successor held that food and water, even when their provision may require technical medical assistance, constitute the “basic care” that patients should receive. The value of such medical assistance is not to be judged by its efficacy in curing the patient or improving the patient’s condition.” I have the impression that while Cardinal Rigali and Bishop Lori explain the Church's position on this issue and point out some errors in the Shannon and Hardt articles, in their writing too could be seen points that are not clear or might be misunderstood. For example thay acknowledge “that this obligation to provide basic care can be exhausted when such assistance can no longer fulfill its basic purpose or finality” that is…when food and water “cannot be assimilated by the patient’s body or cannot be administered to the patient without causing significant physical discomfort”. The question remains who will decide that this physical discomfort is ‘significant’ – since the patient is in PVS, does it leave the decision for the medical professionals? For relatives, if there are any? Then the article speaks about the confusion created by Shannon and Hardt in their respective writings regarding the three exceptions recognized in the C.D.F. Commentary. It would have been good if Cardinal Rigali and Bishop Lori articulate these three exceptions as they see them to be understood correctly. Instead they go on to the question when the treatment is impossible, and they mention the case of poor and undeveloped countries, where the resources are not available. They forget to mention that also in our country, in our developed western society are many for whom this kind of treatment is “impossible”. I don’t think only of the homeless (who are maybe just dumped from the hospitals), but many others without health-insurance maybe don’t even arrive to pose the question of how long to live in PVS, since they die before they reach this condition. Cardinal Rigali and Bishop Lori treat the concept of “burden” that such a care might represent for the patient and they affirm that the “subjective category of burden” is equivalent with dislike for helpless state of life. What if somebody fully appreciates life, yet does not desire this treatment for a motive of solidarity with the before-mentioned poor? The treatment, although not necessary the feeding procedure but the general nursing care is in reality expensive and one might not want it for these reason. Of course, issues of human life never should be pondered on grounds of economical burden, or use death (hastening of death) as a solution for financial problems and so any form of euthanasia is to be avoided. Yet someone might just desire not to receive endless life-support on earth – since as the authors too pointed out “Earthly life is not the highest of all goods, and our hope in eternal life puts in proper perspective all disproportionate and burdensome efforts to sustain life.” At the end I came to the conclusion that in this area probably there is no possibility of giving
Marie Rehbein | 8/1/2008 - 11:48am
As usual, the justification for doing the right thing is presented in an authoritarian tone. The principle that earthly life is to be respected is asserted, while the reason it is to be respected is overlooked. Is it the belief of the Catholic Church that our lives are intended by God to be a preparation of our souls for union with Him or not? Is our conscious enjoyment of life the appropriate indicator of our soul's condition, or is it possible that God continues to communicate with the soul of the incapacitated person who cannot communicate with us? If we believe that we have a soul that eventually moves on to a place (purgatory or heaven) from which it does not communicate with us, then we should allow that the soul embodied in a person who cannot communicate with us could nevertheless be in intense communication with God all the while. It is impossible to keep the body of a dying person alive even if we feed and hydrate it. At that point of natural dying, we can believe that God has chosen to take that individual. Prior to that, if we can provide food and water and don't, then we are taking it upon ourselves to send him or her to God, which is an act of great hubris in my opinion.
ANDY GALLIGAN | 7/28/2008 - 8:40pm
Thia article states "The pope’s condition in his final hours was in no way comparable to that of a P.V.S. patient, who can live a long time with assisted feeding." LIVE a long time? even when reliable medical opinion states that the person will never again regain consciousness? Is it any wonder why hierarchs who defend every non-infallible statement that the Vatican promulgates on morality have lost credibility among educated people? Other viable alternatives that have been put forth by eminent Catholic theologians, theologians who do not believe that fidelity is identical with blind obedience, are never even granted the status of "probable." They are summarily rejected. Ecclesiastical authority is assumed to trump all else in important ethcial matters, and the faithful Catholic response is thought to be obliged to defend whatever Rome has declared. That may be a sincere belief, but it simply out of touch and does not sell. The NATURAL law is meant to be elucidated by reasonable argument, argument that makes sense to educated people of good will. With all due respect there is genuine doubt whether the response by the CDF, defended in this article, does that. It seems shameful to me that good theologians today live in an atmosphere of fear to respond to such "authenitic" statements. I do not believe that is a healthy sign.
ROBERT ROWDEN | 7/28/2008 - 5:24pm
Rigali and Lori overlook an important legal and moral exception to the obligatory use of medically assisted nutrition and hydration. If the patient beforehand or the proxy for the unconscious patient determines that such a procedure offers no hope of benefit or imposes an excessive burden, the assisted hydration and nutrition may be abandoned. No other person has the legal or moral right to make that judgment; certainly not the local Ordinary. Robert M. Rowden M.D.
ROBERT ROWDEN | 7/28/2008 - 5:22pm
Rigali and Lori overlook an important legal and moral exception to the obligatory use of medically assisted nutrition and hydration. If the patient beforehand or the proxy for the unconscious patient determines that such a procedure offers no hope of benefit or imposes an excessive burden, the assisted hydration and nutrition may be abandoned. No other person has the legal or moral right to make that judgment; certainly not the local Ordinary. Robert M. Rowden M.D.