End of life's persistent dilemmas

The bishop's teaching on the medical use of feeding tubes for nutrition and hydration was revised last November to mandate “an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally” that "extends to patients in chronic and presumably irreversible conditions." That revision has drawn the attention of the Chicago Tribune and the Kaiser Health News service, which documents some of the ethical incongruities which emerged at a Catholic hospital when the revised teaching conflicted with the patient's explicit wishes and local law. The stories suggest that, despite the bishop's recent attempts to clarify this specific end-of-life question, Catholic families, their doctors and staff at Catholic institutions are going to continue to grapple with practically and lovingly interpreting church teaching when confronted personally by these difficult questions.

From Kaiser's report:


An elderly woman taken last year to St. John Medical Center in Tulsa, Okla., had suffered a massive stroke and could no longer speak, eat or drink. Although she had an advance directive specifying no artificial hydration or nutrition if she weren’t going to recover, local health officials said, her nephew insisted the local bishop’s directive on use of feeding tubes required the Catholic hospital to install one.

Her doctors and St. John officials debated how to proceed, struggling with ethically charged issues that hundreds of Catholic hospitals and nursing homes could face under new doctrine. In November, the U.S. Conference of Catholic Bishops approved a revised ethical and religious directive similar to the Tulsa bishop’s. It states in part that Catholic health facilities have “an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally.” 

"This obligation," the bishops said, "extends to patients in chronic and presumably irreversible conditions," such as persistent vegetative state, who might live for many years if given such care. A feeding tube is not required, however, if it wouldn’t prolong life, would be “excessively burdensome for the patient,” or would “cause significant physical discomfort.”

The directive raises fresh questions about the ability of patients to have their end-of-life treatment wishes honored — and whether and how a health care provider should comply with lawful requests not consistent with the provider’s religious views. Hospitals and nursing homes do not have to comply with requests that are "contrary to Catholic moral teaching," according to longstanding policy that, as in the case of the revised directive, applies to non-Catholic patients as well. 

If a patient or family didn’t want a feeding tube “and the reason they don’t want it is they basically want to die, then the Catholic institution would explain to them they can’t cooperate with that and they would have to go to another institution,” said the Rev. Thomas G. Weinandy, executive director for doctrine at the bishops’ conference, who helped draft the policy.

Experts say no other large health systems in the U.S. have nutrition and hydration policies like those governing Catholic facilities. 

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Helena Loflin
8 years 10 months ago
Beth, excellent question.  I guess a Catholic who has suffered a massive stroke or is in some other dire life-ending condition does not have the option of offering themselves up to God, only his/her suffering. 
For days before my extremely frail mother died of heart failure at age 91 a few years ago, she no longer wanted to or could eat or drink.  I cannot imagine my two sisters and I requesting or demanding a feeding tube for her.  To what end?  Prolonging her dying?  It certainly would not have been prolonging her life.
And, what about the female martyrs who chose death over rape?  Shouldn't they have chosen life above everything else?  Or, was being raped back in the good old days such a grevious sin that the future martyrs were better off dead?
Beth Cioffoletti
8 years 10 months ago
How is it that we canonize as martyrs those who volunteer to be fed to the lions for their faith, but refuse patients the dignity of refusing food and water?
David Nickol
8 years 10 months ago
Suppose a patient is totally paralyzed, blind, and unable to communicate except by some very cumbersome method such as blinking his eyes. Suppose he is also in excruciating pain, say, from some kind of spinal injury. But suppose he is not dying. While the feeding tube in an of itself might not be an extraordinary measure to keep him alive, it keeps him alive in both physical and psychological agony. May he not decide under the circumstances to discontinue medical treatment? 
A person in a persistent vegetative state cannot say "I can't stand to live like this," because they are not aware. But can't a fully aware person make a judgment that medical treatment is too burdensome to continue?
8 years 10 months ago
A Catholic hospital might be a place of a ''good'' death with appropriate spiritual and comforting care.  But instead they are mandating every artificial thing be done to prolong life past its normal natural end.   
Marie Rehbein
8 years 10 months ago
It seems to me that people are jumping to conclusions and not giving enough weight to that part of the directive that says, "A feeding tube is not required, however, if it wouldn’t prolong life, would be 'excessively burdensome for the patient,' or would 'cause significant physical discomfort.'"
If any of those three things were to be the case, then a feeding tube is not required.  A 91 year old woman with heart failure would not be a candidate for a feeding tube by these guidelines.  However, a person who is in pain and would rather die because of it, should realize that starving himself or dehydrating himself to death is morally equivalent to euthansia unless feeding and hydrating would increase the pain.  
The idea is that people whose existences do not conform to what most people would want should not be deprived of food and water just because they cannot say they whether they do or do not want it.
David Nickol
8 years 10 months ago
I do not actually know the answer, but from what you say, it would indicate to me that it is only when a person is dying that he or she may refuse medical treatment. Is this indeed Catholic teaching? 
The Catechism says:
2278 Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of ''over-zealous'' treatment. Here one does not will to cause death; one's inability to impede it is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected.

2279 Even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted. The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only foreseen and tolerated as inevitable Palliative care is a special form of disinterested charity. As such it should be encouraged.
James Lindsay
8 years 10 months ago
Thank you for sharing this piece, which identifies the priest responsible for injecting ideology into what should be a private matter. This pronouncement appears to have been issued for the wrong reasons - coalition politics in the Pro-Life movement in reaction to Terri Schaivo's case. The Florida Catholic Conference was right the first time. Indeed, the current letter is incomplete, since it does not even examine the case of someone who has been brought back from death without ever regaining consciousness. Hoepfully advances in emergency medicine, such as the cooling of patients who have been brought back, will make such questions moot in the future.

One would have hoped that the Bishop of Tulsa would have followed the example of Pope John Paul II, who was not given a feeding tube as he was dying of sepsis.
Jim McCrea
8 years 10 months ago
Simple solution:  make darned sure that you are NOT admitted to a Catholic hospital when you get to that stage in your life.
James Lindsay
8 years 10 months ago
There is no chance of that in N. Virginia. There are none here. Also, INOVA doesn't even have a Catholic Chaplain. Strangely, NIH does. When my father had a heart attack and was brought back partially here (and mostly dead) the ICU folks knew he was dying. If it were not for my mother, he would have been exubated fairly quickly. There was never talk of a feeding tube and we refused dialysis for him. Luckily, he expired in a week. Of course, today he have been given hypothermia treatment to cool him and would have likely woken up in a week - fully conscious. Of course, as a conservative Catholic, he would have been really ticked off at political events over the last few years and would likely be logged on here arguing with me. The point is, of course, that your prospects are controlled by which Catholic hospital you are in. At Mercy Hospital in Cedar Rapids they did not get overly aggressive. Stay out of Catholic Hospitals in Oklahoma (or other red states).
Marie Rehbein
8 years 10 months ago
I don't know the ins and outs of the many, many day to day things upon which the Catholic Church has issued opinions.  However, it is my impression that they do this because people expect them to.  It is my observation that these opinions are little more than common sense derived from holding to certain principles.  Obviously, in this case, the principle is that one does what one can to support earthly human life so that the end of it, just like the beginning, is left up to God.
It would be my belief that a Catholic could at any time refuse medical treatment. Illness and disease are natural processes, and there is no requirement that one interfere with the course of nature. 
However, when people cannot eat, drink, or breathe on their own and cannot make it known that they decline artificial feeding, hydration, or ventilation, the assumption should not be that because one cannot imagine wanting to be in such a state that thus one would want to be left to starve, dehydrate, or suffocate.
It seems rather obvious to me that if a conscious, reasoning person feels no desire for food, then the Catholic Church is not expecting that person to request what would amount to force feeding.  However, if one is in a weakened condition, and one is advised that hydration, for example, would do much to improve that, one cannot decline it on the basis that one wishes to be dead.
It has been my experience that Catholic hospitals honor "do not resuscitate" orders.


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