Accompanying the congregations response is a commentary that provides a rationale for its decision and notes three important exceptions: a physical impossibility, such as the unavailability of feeding tubes; the inability of a patients body to assimilate nutrition or hydration; and medical complications from assisted nutrition or hydration.
Both the response and the commentary raise questions about the state of church teaching on this matter. For all patients, including those in a permanent vegetative state, the common Catholic tradition has sought to determine what benefits an intervention would provide and whether the burdens of intervention are proportionate or disproportionate to the expected benefits. It is clear that the provision of artificial nutrition and hydration to a person is based on a technology that works: nutrients and fluids are delivered and the patient generally ingests them. But is that the end of the analysis? Is the end part of an overall plan to return the patient to health, to gain time so that other needed interventions can be made? Or is it simply to keep the patient physically alivethat is, apparently, to maintain biological life for its own sake?
Has the Church Changed Course?
The doctrinal congregations August announcement stands in contrast to a document it released in 1980, the Declaration on Euthanasia. That declaration explains that one can correctly judge whether a treatment is ordinary or extraordinary 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. The declaration reflects the wisdom of the common Catholic moral tradition, which seeks to determine whether a particular treatment is extraordinary by evaluating its impact on the health and well-being of the patient, others and the general society.
This declaration is also in harmony with the methodology used by Pius XII to determine whether the newly introduced ventilator was ordinary or extraordinary. He defined ordinary in terms of the circumstances of persons, places, the times and the culture and not imposing a grave burden on ones self or another. His answer did not base the analysis on the nature or a classification of the technology itself, as the current analysis by the congregation seems to do. Rather the pope took the common teaching about ordinary and extraordinary means and used this to resolve the case.
According to the current state of medical knowledge, the persistent vegetative state is irreversible; all one can do for such a patient beyond providing basic care is to maintain the biological signs of life. Providing artificial nutrition and hydration, therefore, does not contribute to the patients recovery or necessarily maintain the patients stable condition. In some instancesand these are not rare cases, as the congregations document suggestssuch interventions can harm the patient, given side effects such as infections at the insertion point of the tube, nausea, vomiting and the possibility of the vomitus choking the patient. Some patients occasionally tear out their tubes, and health care providers are required to restrain them physically. Whether this tearing out is done consciously or unconsciously, the tube must be reinserted, often surgically, which exposes the patient to further risks. Well-documented medical literature recounts the harms and burdens associated with tube-feeding.
Such maintenance violates the dignity of the person, because it defines and reduces their personhood solely to terms of biological functioning. It is physical reductionism, a form of materialism that benefits neither them nor society. And the position seems to confer on physical life an almost absolute value.
The Costs of Care
The congregations August commentary claims that providing artificial nutrition and hydration does not involve excessive expense, that it is within the capacity of an average health-care system and does not of itself require hospitalization. (It recognizes that in cases of extreme poverty the provision of A.N.H. may be impossible; hence is not obligatory.)
Still, the insertion of a feeding tube often involves a surgical procedure; minimally it is an outpatient procedure. Once inserted, the tubes must be monitored regularly to prevent infection and to maintain placement during routine care (moving a patient to prevent bed sores, for example). The document seems to assume that since inserting the feeding tube does not require hospitalization and is not of itself excessively expensive, a patient can be cared for at home.
In the United States, however, the vast majority of persons in a permanent vegetative state reside in nursing homes, where a semi-private room (not including most ancillary medical expenses) costs more than $60,000 a year. Most relatives of patients cannot stay at home during the day, even if they want to, in order to care for family members. Nor does everyone have insurance coverage for such patient care. Even for the insured, the cost of coverage and co-payments is significant and complex, since coverage may change annually when employers negotiate contracts with different insurers.
Regardless of the actual dollar expense of providing artificial nutrition and hydration, which is what the congregations commentary focuses on, another question must be addressed: How longhow many years ordecades?is a patient in a permanent vegetative state obligated to undergo tube feeding, in light of the impact on his or her family and the larger community? Could a prolonged duration of A.N.H. make it so burdensome that the treatment is seen then as extraordinary rather than ordinary?
The 1980 Declaration on Euthanasia notes that the refusal of extraordinary treatment is not the equivalent of suicide; on the contrary it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community. Consider the social justice dimension of the statement, which asks us to assess the economic impact on the larger society, even in cases that are not considered extreme. Thus, even though an insurance policy might cover all or part of the cost of A.N.H., one may not be obliged to utilize the coverage.
The 2007 commentary seems to misread the 1980 declaration by assuming that the latters discussion of proportionate or disproportionate treatment refers only to means of treatment when death is imminent. This is not the case. The congregations 1980 statement does discuss obligations when death is imminent; but if one reads the entire section where that reference is made, one finds a larger discussion of the general question of ordinary and extraordinary means of treatment and the legitimacy of withdrawing or forgoing extraordinary means of treatment even when death is not imminent.
The common moral tradition of discussion about ordinary and extraordinary means of interventionor the use of proportionate and disproportionate intervention, as the discussion is now framedextends backward from recent papal and other ecclesiastical or magisterial documents to at least the 1500s. The history of this tradition and its development is extremely important in helping to clarify issues such as the use of feeding tubes. The common moral tradition determined whether an intervention was proportionate on a case-by-case basis, independent of the technology, by looking at the effects on the patient, the family and the larger society. The assumption was that the patient, in consultation with physicians and in relation to the circumstances of his or her life, could come to a correct judgment.
Now, by contrast, an authority classifies the intervention by abstract means based on the nature of the technology, independent of its effect on the patient, and determines whether an intervention is proportionate. This could mean that whenever a new technology is introduced, local churches would have to appeal to the Congregation for the Doctrine of the Faith to find out what to do.
The Case of John Paul II
The dispute over the feeding tube used by Pope John Paul II (see Popes Death Drawn Into Euthanasia Debate, by Ian Fisher, The New York Times, 9/18/07) is an example of the kind of debate one is drawn into when the focus of the ethical decision becomes technology instead of the patient. The doctrinal congregations August commentary gives moral priority to technology by submitting the evaluation of benefits to an impersonal biological standard. Such has not been the common moral tradition, which centers attention on the patient and seeks to provide benefits but wisely realizes that the time for cure can pass and that continued technological assistance can become increasingly burdensome. That is the time for ceasing such interventions, increasing basic care of the patient and accompanying him or her on the next phase of the journey to the Lord.
Consider the case of Pope John Paul II. Recall that during several of his hospitalizations he had a feeding tube that was maintained for a time and then removed. During his final hospitalization, no feeding tube was inserted, nor was one mandated. Doing so would have been easy enough: he had a small clinic set up in his bedroom at the Vatican. Perhaps artificial nutrition and hydration was not mandated because John Paul II was not in a permanent vegetative state. But that raises the question, Is the use of A.N.H. mandated in cases other than P.V.S.? If the use of artificial nutrition and hydration is in principle a proportionate means of preserving life, as the August 2007 document notes, then should it not have been provided to the pope? Is the lack of its provision in the popes case an exception? If so, it would be helpful to know the basis of the exception and who made such a determination.
Perhaps the course of John Pauls dying affords moralists an example of how to think through the use of artificial nutrition and hydration in light of the common moral tradition. The decision to forgo A.N.H. is clearly consistent with the analysis and methodology of the common moral tradition, the 1980 statement and previous statements by the Congregation for the Doctrine of the Faith.