Is the removal of a feeding tube that supplies nutrients and fluids, especially in patients in a persistent vegetative state (PVS), simply a means of killing a vulnerable persona form of euthanasia? Judging from some of the responses to the much-publicized Terri Schiavo case, it seems there are those who think so, including a fair number of Catholics. (Ms. Schiavo, a 39-year-old Florida resident, suffered severe brain damage after a collapse in 1990 and has been sustained since then by a feeding tube. Her husband has sought the removal of life-sustaining equipment. This is opposed by her parents and family, and the issue has been litigated for over five years.)
It is not always clear whether those who oppose removal of the feeding tube do so because they believe it is killing in this particular case or that it is killing in most or all such cases. In any event, the Terri Schiavo case has generated not only enormous controversy, but also considerable confusion among Catholics and others regarding the moral justification for forgoing artificial nutrition and hydration.
The confusion, however, did not originate with the Terri Schiavo case. Reactions to other high-profile feeding-tube cases over the last 20 years or so have also contributed to the confusion. In general, this confusion has arisen because differing viewpoints have been expressed by church-related bodies discussing Catholic teaching on the duty to preserve life by providing nutrition and hydration (e.g., statements by the New Jersey and Texas bishops). More seriously, many of the statements that have been issued since the Vatican’s Declaration on Euthanasia (1980)appear to revise and apply in a narrow way traditional Catholic teaching on the matter. In what follows, we offer a brief sketch of the tradition, then consider the two principal ways in which the tradition is being revised and, finally, reflect on the implications of these revisions.
Traditional Catholic Teaching
The Catholic tradition on the duty to preserve life has developed over the course of some 500 years. Two Jesuit moralists, John J. Paris and the late Richard A. McCormick, presented an excellent summary of this tradition as it relates to the use of nutrition and hydration (Am., 5/2/87). We would like to highlight three important features of that summary for background purposes.
Duty to preserve life. The bedrock for the traditional teaching is found in the basic Christian understanding of life and death. As Christians we believe human life is a great good that has been given to us freely out of love by God, and through life we are able to enter more fully into communion with God by loving others. We therefore have a duty to protect and to preserve our lives. Yet this duty is not absolutely binding under all circumstances, because we know our ultimate end lies in eternal life with God. Just what circumstances might relieve us of our duty to preserve life is a question that has been given considerable attention in the tradition.
It has been widely accepted among Catholic moralists since the 16th century that one need only employ ordinary means of preserving life but not means that are deemed extraordinary, by which is meant measures that either fail to offer a proportionate hope of benefit or that impose an excessive burden. This distinction between ordinary and extraordinary means was first articulated explicitly by Dominican moralist Domingo Bañez (1528-1604) and it is still operative today, though now the terms proportionate and disproportionate are more often used.
The relative norm. There has been a shift away from the traditional terms because the meaning of ordinary and extraordinary began to be seriously misunderstood as medicine became more advanced and certain means of preserving life became more commonly used and readily available. As a consequence, the moral question regarding the effects of a particular therapeutic means upon a person in terms of benefits or burdens was reduced to a technical question about the means itself. If the means, without respect to the overall impact on the person, were an ordinary medical procedure or therapy, it was wrongly deemed ordinary in the moral sense of the term and hence obligatory. For the traditional moralists, however, no means of preserving life could be considered ordinary apart from an assessment of the benefits or burdens relative to the person’s overall situation.
That this is true can be seen in the most comprehensive historical study of the topic, the 1958 doctoral dissertation of Daniel A. Cronin, who is now archbishop emeritus of Hartford, Conn. In discussing how one judges whether a means is ordinary and hence obligatory, Archbishop Cronin stated:
the notion of proportionate hope of success and benefit is an essential part of the nature of ordinary means. Without this hope of benefit, a means is hardly an ordinary means and therefore is not obligatory. In determining the presence of this hope of success and benefit, one must consider not only the nature of the particular remedy or means involved, but also the relative condition of the person who is to use this means. Then, and then only, can the moral obligation of using such a means be properly determined.
This relative understanding of means is also seen in recent authoritative statements. In the Declaration on Euthanasia, for instance, we read: It will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources. Likewise, Pope John Paul II stated in his encyclical letter Evangelium Vitae (1995): Certainly there is a moral obligation to care for oneself and to allow oneself to be cared for, but this duty must take account of concrete circumstances. It needs to be determined whether the means of treatment available are objectively proportionate to the prospects for improvement.
Nutrition and hydration. Obviously the traditional Catholic moralists did not have to contend with questions about feeding tubes. But they did consider the moral obligation one has to preserve one’s life with food and fluids. Given what was said above, it will not be surprising to learn that even such mundane means as food and fluids could be forgone if they failed to provide a proportionate hope of benefit or imposed excessive burdens. The Dominican moralist Francisco De Vitoria (1486-1546) made this clear when he argued that if the depression of spirit is so low and there is present such consternation in the appetitive power that only with the greatest of effort and as though by means of a certain torture, can the sick man take food, right away that is reckoned a certain impossibility, and therefore he is excused, at least from mortal sin, especially where there is little hope of life or none at all.
De Vitoria’s views were not unique among traditional moralists, nor were they subsequently rejected by contemporary ones. This is evident in the article The Duty of Using Artificial Means of Preserving Life, published by the Jesuit moralist Gerald Kelly (1902-64) in Theological Studies in June 1950. In discussing whether oxygen and intravenous feeding must be used to preserve the life of a patient in a terminal coma, Kelly stated: I see no reason why even the most delicate professional standard should call for their use. In fact, it seems to me that, apart from very special circumstances, the artificial means not only need not but should not be used, once the coma is reasonably diagnosed as terminal. Their use creates expense and nervous strain without conferring any real benefit.
Revisions of the Teaching
By all accounts, the Catholic tradition on the duty to preserve life remained substantively the same from the early 16th century through the Holy See’s Declaration on Euthanasia in 1980. But since then, there has been a concerted effort by some to revise traditional Catholic teaching on the use of nutrition and hydration generally, and particularly in its application to patients in a persistent vegetative state. This has been done in two significant ways. The advocates of revision claim that nutrition and hydration are always obligatory, and they severely limit the meaning of the term benefit.
Nutrition and hydration always obligatory. Some of those attempting to revise the tradition define artificial nutrition and hydration as care, basic care or minimal measures for sustaining life and then assert that providing this care is always morally obligatory. For example, in its 1981 document, Questions of Ethics Regarding the Fatally Ill and Dying, the Pontifical Council on Health Affairs stated: there remains the strict obligation to apply under all circumstances those therapeutic measures which are called minimal’: that is, those which are normally and customarily used for the maintenance of life (alimentation, blood transfusions, injections, etc.). To interrupt these minimal measures would, in practice, be equivalent to wishing to put an end to the patient’s life (emphasis added).
Similarly, in the Report of the Pontifical Academy of Sciences on the Artificial Prolongation of Life (1985), we find the statement: If the patient is in a permanent, irreversible coma all care should be lavished on him, including feeding (emphasis added). The New Jersey Catholic Conference, in its 1987 statement, Providing Food and Fluids to Severely Brain Damaged Patients, also maintained that nutrition and hydration, being basic to human life, are aspects of normal care, which are not excessively burdensome, that should always be provided to a patient (emphasis added). Forgoing these means ultimately results in starvation, dehydration, and death. It is direct. It is unnatural, as unnatural as denying one the air needed to breathe, or murder by asphyxiation.
This distinction between care and treatment seems to be a new development; the closest thing to it in the tradition is the distinction between natural and artificial means, which is morally irrelevant, as we will see. Certainly dying persons must always be cared for in ways that respect their inherent dignity. Traditionally, however, this has not meant that food and fluids must always be provided. The traditional moralists understood that even the most common or natural means of preserving life could be extraordinary and hence morally optional. Archbishop Cronin made this clear: even the older moralists teach that such a purely ordinary and common means of conserving life as food admits of relative inconvenience and difficulty. Furthermore, they point out that this very common means, food, sometimes can offer no proportionate hope of success relative to a particular individual.
If this could be said of food and fluids, it would seem to apply all the more to various forms of artificial nutrition and hydration delivered through IV lines, nasogastric tubes and gastrostomies. For the traditional moralists, the decisive moral consideration was not how basic a particular means was to life or how commonly or easily available it was. Rather, it was whether the means offered a proportionate hope of benefit without imposing excessive burdens relative to the person’s overall situation.
We point out, as an aside here, that it seems logically inconsistent to classify nutrition and hydration as basic care that is always obligatory even if artificially supplied, while not doing the same for oxygen supplied by mechanical ventilation or other basic elements of care necessary for life. Why does nutrition and hydration merit such a classification? As we see it, the case for doing so has not only not been adequately made; it has not been argued at all.
Meaning of benefit severely restricted. Some of those attempting to revise the tradition also restrict the notion of benefit simply to the preservation of physical life itself. For example, in Nutrition and Hydration: Moral and Pastoral Reflections, the U.S. Bishops’ Pro-Life Committee commented in 1992 that such measures [nutrition and hydration] must not be withdrawn in order to cause death, but they may be withdrawn if they offer no reasonable hope of sustaining life or pose excessive risks or burdens (emphasis added).
In a qualitatively major shift, the Pro-Life Committee replaced the traditional language of proportionate hope of benefit relative to the person with reasonable hope of sustaining life. The Florida Catholic Conference similarly restricted the notion of benefit in much the same way, albeit in negative terms, in its statement regarding Terri Schiavo: Bishop Lynch’s statement clarifies the teaching of the Church that nourishment or hydration may be withheld or withdrawn where that treatment itself is causing harm to the patient or is useless because the patient’s death is imminent (emphasis added). The assumption here appears to be that nutrition and hydration naturally or artificially supplied are always beneficial, except when they fail to sustain life because death is inevitable regardless of what is done.
This limited physical understanding of benefit is not the way traditional moralists understood it. The mere fact that a means was capable of sustaining life did not necessarily mean it was beneficial to the person. De Vitoria argued this point when he stated that one is not held to lengthen his life, because he is not held to use always the most delicate foods, that is, hens and chickens, even though he has the ability and the doctors say that if he eats in such a manner, he will live 20 years more; and even if he knew this for certain, he would not be obliged (emphasis added).
Admittedly, the meaning of benefit is hard to define because of the relative factors involved. One thing is certain, however: the traditional moralists did not restrict benefit merely to sustaining life but included broader, more holistic considerations. Improvements in one’s condition, relief of pain, maximization of comfort, restoration of health, among othersall were considered beneficial. Yet, as we read the tradition, these physical effects were beneficial insofar as they enabled one to pursue human goods bound up with physical life and spiritual goods that transcend it, at least at a minimal level, without imposing excessive burdens. This explains why De Vitoria said that even a means that could sustain life for another 20 years would not be morally obligatory. For De Vitoria and other traditional moralists, the mere preservation of physical life and vital physiological functions was not sufficient in itself to oblige someone to use a certain means, including food and fluids.
From our quick review of at the Catholic tradition on the duty to preserve life and some recent church statements on nutrition and hydration, we can see that the traditional teaching is being revised. In essence, two standards for making decisions about nutrition and hydration have emerged and now exist side by side. One is a more holistic standard based on the traditional teaching, in which benefits and burdens are understood broadly relative to the person, and any means of preserving life is subject to a benefit-burden analysis. The other is a more restrictive standard based on recent revisions of the traditional teaching, in which benefits and burdens are understood narrowly, apart from relative factors, and nutrition and hydration are given a special moral classification.
Proof of this can be seen inthe fourth edition of Ethical and Religious Directives for Catholic Health Care Services, published in 2001 by the U.S. Conference of Catholic Bishops to provide authoritative ethical guidance to Catholic health care providers. The introduction to Part 6, for instance, states the more restrictive standard: These statements agree that hydration and nutrition are not morally obligatory either when they bring no comfort to a person who is imminently dying or when they cannot be assimilated by the person’s body (emphasis added).
In all the opinions we have considered from the traditional moralists and in all of our studies of the tradition, nowhere do we see the exceptional circumstances under which one may morally forgo a means of preserving life reduced to imminent death or futility simply because it will not work. For the traditional moralists, these were the easy cases. What they strained over and worked out was a practical moral standard for the gray-area cases, of which we see shades in the latter part of E.R.D. Directive 58: There 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 to the patient (emphasis added). Here benefits and burdens are not explicitly defined in a narrow way. When this directive is read against the backdrop of Directives 56 and 57 on the definitions of ordinary and extraordinary means, the E.R.D. returns to the more traditional understanding.
The confusion among Catholics about the church’s teaching on forgoing artificial nutrition and hydration, as evidenced by the Terri Schiavo case and others like it, is due largely to the fact that we now have two standards for making decisions. What are we to make of this? Could it be that we are experiencing a development of church teaching toward the more restrictive standard? This might be.
In 1998, Pope John Paul II lent credence to the view that nutrition and hydration are ordinary or proportionate means, and hence morally obligatory, when he stated during an ad limina visit in Rome by U.S. bishops from California, Hawaii and Nevada that a great teaching effort is needed to clarify the substantive moral difference between discontinuing medical procedures that may be burdensome, dangerous or disproportionate to the expected outcome and taking away the ordinary means of preserving life, such as feeding, hydration and normal medical care (emphasis added).
The pope seemed to go further in an audience in March 2004, speaking to participants in an international conference on nutrition and hydration and the vegetative state that was sponsored by the World Federation of Catholic Medical Associations and the Pontifical Academy for Life. On that occasion, the pope stated that sick people in a vegetative state, waiting to recover or for a natural end, have the right to basic health care (nutrition, hydration, hygiene, warmth, etc).
He went on to underline how 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, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering (emphasis in original).
It is not entirely clear at this time what the implications of these papal statements are for Catholic patients, families, caregivers and health care organizations. Some believe that by his latest statement, the pope has made nutrition and hydration morally obligatory for all patients under all circumstances and has thus altered a tradition of more than 500 years. But an alternative reading is also possible. Although the pope definitely narrows traditional teaching by claiming that nutrition and hydration are ordinary, apart from relative factors, he does not radically and completely depart from traditional understandings or his own previous teachings by making their use an absolute requirement with no exceptions. If the pope’s statement is read in light of the tradition, what he might be saying is that in principle nutrition and hydration are ordinary means of preserving life and hence morally obligatory for all patients. This appears to be just a continuation of what we have seen already in the U.S. bishops’ Pro-Life Committee document of 1992 and in Directive 58, where we hear of a presumption in favor of providing nutrition and hydration.
Were the pope going beyond this presumption and arguing instead for an absolute requirement, he would not likely have uttered the phrase insofar as and until it is seen to have attained its proper finality (emphasis added). Here the pope may be indicating that nutrition and hydration are not always obligatory, but only to the extent that they serve their ultimate purpose. Furthermore, and most important, the pope goes on to specify just what this proper finality isbut only for patients in a PVS. He does this by saying, which in the present case consists in providing nourishment to the patient and alleviation of suffering (emphasis added). The present case refers to those in a PVS, which was the focus of the conference and of the pope’s statement read at the conclusion of the conference. So we may well be left with a presumption in favor of providing nutrition and hydration to all patients. But nutrition and hydration can be withheld or withdrawn when they do not attain their proper finality, which for patients in general can be decided on traditional grounds (i.e., holistic benefit-burden analysis) and for patients in a PVS on the more limited grounds set by the pope (i.e., nourishment and alleviation of suffering).
Whatever the pope intended to say about the particulars of caring for PVS patients, his general purpose for making the statement seems clear. He has spoken frequently about a culture of death that pervades modern society. In that context, he seems especially worried that forgoing nutrition and hydration from vulnerable patients (e.g., those in a PVS) could easily degenerate into euthanasia. The documents to which we have referred and others as well echo this concern. The New Jersey Catholic Conference document, for example, states: Today food and nutrition is withdrawn from someone in a persistent comatose state; tomorrow such care is withdrawn from someone suffering from Alzheimer’s disease.
The concern is legitimate, especially with regard to those who are unable to speak for themselves. Undoubtedly, forgoing life-sustaining treatment, including artificial nutrition and hydration, can be abused. It can take the form of euthanasia. The possibility that this will happen is perhaps greater than ever today, with physician-assisted suicide (P.A.S.) gaining wider support and our collective appreciation for life eroding. But we must all carefully consider whether a narrow revision and application of the tradition is the most effective response to this threat. Instead of limiting abuse, such a narrowing could have the opposite effect. It could, in fact, propel requests for P.A.S. and euthanasia. Let us not forget that the reasons for requesting P.A.S. center on fear of dying in pain, fear of being a burden to others or fear of having life unreasonably prolonged.
Furthermore, such a revision has no hope of being effective if it does not resonate with the best of human experience and if it is not persuasive. To date, the case for restricting the forgoing of artificial nutrition and hydration has not been adequately made. Nor have the statements proposing such a restriction addressed modern medical evidence showing that artificial nutrition and hydration are not always beneficial and can impose serious burdens on the patient. A more restrictive standard crafted in light of exceptional cases does not seem indicated, given the medical evidence to the contrary. Moreover, such a standard is not supported from a biological standpoint, since most dying persons naturally stop eating and drinking.
Perhaps a more constructive approach to securing the dignity of the dying and preventing abuses is not to react to the negative possibilities. A better approach might be to seek to transform our contemporary culture by honoring the traditional teaching and developing quality palliative care programs that can address the holistic needs of seriously ill and dying persons as well as the concerns of their families. Witnessing to the dignity of those who are approaching the mystery of death is likely to have a far greater transformative effect on attitudes toward the dying and the vulnerable than restricting or narrowing our centuries-long tradition in ways that could well impose additional burdens on these patients and their families. It may be that neither this consideration nor any other would have helped resolve the Terri Schiavo case, given the great divide between her loved ones. However, in the majority of cases involving decisions to forgo nutrition and hydration or any other means of preserving life, the traditional teaching and a comprehensive palliative care strategy will be effective Christian witness to our basic understanding of life and death.