What we teach is firmly rooted in the religious conviction (widely endorsed far beyond the Roman Catholic communion) that human life is sacred, that it comes from God and that the direct and deliberate taking of innocent human life is a most basic sort of moral wrong.
3.
The Congregation for the Doctrine of the Faith emphasizes the need for science and technology to be at the service of the human person in The Instruction on Respect for Human Life in Its Origin and On the Dignity of Procreation, Vatican Polygot Press, Vatican City, 1987, p. 7.
4.
The terms “body” and “soul” as they are used here are not, of course, medical terms. They are philosophical terms which have been incorporated into the theological tradition in order to express the reality of the spiritual and physical components which together make up the whole person.
5.
A listing of various types of unconsciousness may be found in The Merck Manual of Diagnosis and Therapy, Robert BerkowM.D., Editor-in-Chief, Fifteenth Edition, Merck Sharp & Dohme Research Laboratories, Rahway, New Jersey, 1987, pp. 1331–1335.
6.
“Uniform Determination of Death Act,”President's Commission For the Study of Ethical Problems in Medicine and Biomedical Research, Defining Death, 1981, pp. 72–73.
7.
The Harvard criteria came from a study conducted at Harvard Medical School in 1968. The criteria were not intended to replace the classical indicators of death, but were developed specifically for use in those cases where the determination of death might be questionable. Basically, the criteria came down to the following: (1) There should be total unawareness to externally applied stimuli, even those which are painful. (2) Observations of at least one hour by physicians reveal no spontaneous muscular movements or spontaneous respiration or response to any stimuli. If a patient on a mechanical respirator has normal carbon dioxide tension and has been breathing room air through the respirator for at least ten minutes, the respirator may be turned off for three minutes in order to observe whether there is any spontaneous effort at breathing, (3) There are no elicitable reflexes. The pupil is fixed and dilated and does not respond to light or pinching of the neck. Ocular movement and blinking are absent. There are no stretch, tendon, plantar or noxious stimuli responses. (4) The proper administration of an electroencephalogram (EEG) gives a flat reading. This criterion is considered confirmatory, but is never a sufficient indicator in itself. (5) All of these tests should be repeated 24 hours later, with no change. (More recent versions of the criteria limit the time to 12 or even 6 hours duration.) (6) The validity of these criteria is also cast into doubt if the cause of the condition is hypothermia or drugs which depress the central nervous system. [This summary of the criteria is based upon the description given by O'DonnellThomas J., S.J., in, Medicine and Christian Morality, Alba House, New York, 1976, pp. 112–114 Cf. “A Definition of Irreversible Coma: Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death,” in Journal of the American Medical Association (hereafter referred to as JAMA), 205: 337-340, August 5, 1968.] That brain death includes loss of total brain function — including that of the brainstem — is widely accepted. (Cf. Uniform Determination of Death Act, 1981; Fred Plum, M.D., and Jerome B. Posner, M.D. The Diagnosis of Stupor and Coma, Third Edition, Third Printing, (Philadelphia: F. A. Davis Company, 1982), pp. 315-316; Benedict M. Ashley, OP, Kevin D. O'Rourke, OP Health Care Ethics, Third Edition (St. Louis: Catholic Health Association, 1989), pp. 366-368.
8.
As Doctor C. Everett Koop points out, there is need for continuing revision of norms for the determination of death. He says: “I think the situation can be very briefly summarized this way: what used to be called brain death wasn't brain death; it was the cessation of electrical activity on the cortex or thinking part of the brain as measured by electroencephalography. Today, brain death, which has tremendous relationship to procurement of organs for transplantation, means not only death of the cortex but total brain death, including the brain stem.” (Everett KoopC., To Live or Die? Facing Decisions at the End of Life, Servant Books, Ann Arbor, Michigan, 1987, p. 41.)
9.
A brief description of states of unconsciousness may be found in The Merck Manual, pp. 1331-1335. A slightly more detailed one is given by Fred PlumM.D., and PosnerJerome B.M.D., The Diagnosis of Stupor and Coma.Third Edition, Third Printing, F.A. Davis Company, Philadelphia, PA, 1982, pp. 1–9.
10.
Even the Harvard Medical School comittee, in its development of the criteria for brain death, led to some confusion in its use of the term “irreversible coma” as though this could be equated with death. The comatose patient is not dead. One could, however, excuse that lapse since the document was written more than 20 years ago when there may still have been lacking some of the refinement of terminology that has since emerged.
11.
Cf. Council on Scientific Affairs and Council of Ethical and Judicial Affairs, “Persistent Vegetative State and the Decision to Withdraw or Withhold Life Support,” inJAMA, 263: 427, January 19, 1990. The text reads: “Abrupt loss of consciousness usually consists of an acute sleep-like state of unarousability called coma that may be followed either by varying degrees of cognitive and physical recovery or by severe, chronic neurological impairment. The stage of coma itself, however, is invariably temporary and in progressive disease is often absent altogether.”
12.
The lack of function of the cerebral cortex is confirmed by the lack of human behavioral responses and by the lack of normal metabolic activity. The former can be seen by external observation, the latter can be confirmed by the use of positron emission tomography (PET scans), which measure the brain's use of glucose. It should be noted that an EEG may offer evidence of cortical activity, but it should also be kept in mind that the EEG is capable of measuring activity only on the outermost centimeter of the brain's tissue. Even though current techniques for examining the condition of the brain become increasingly sophisticated, it should be noted that in many instances the real extent of brain damage cannot be fully assessed until a post mortem examination can be done.
13.
It should be noted that this state is referred to as “vegetative,” but that this should not be taken to mean that the person has become a “vegetable.” This latter term is often used in a pejorative sense, when, in fact, the word “vegetative” refers rather to a level of functioning that is at an involuntary level and is sufficient to continue vital life processes, such as respiration, digestion, sometimes swallowing, etc.
14.
That the PVS patient is not dead seems clear from the few reported cases in which such patients have revived either permanently or temporarily. On March 29, 1990, the Associated Press reported the case of a patient in Madison, WI, who had been a PVS patient for eight years and was accidentally revived when given a dose of Valium during the course of dental work. Combinations of drugs have kept him in lucid states for periods of 10 to 12 hours at a time since then. Time (March 19, 1990, pp. 70-72) reported the case of a woman whose husband had requested the courts for permission to remove life sustaining equipment after doctors told him that she was in persistent vegetative state. The courts refused, and six days later she woke up and is now in normal condition, except for some minor memory lapses.
15.
JAMA, 263: 428, January 19, 1990.
16.
JAMA, p. 428.
17.
Relying on natural law and divine revelation, Catholic moral teaching has identified two basic moral principles as expressive of the moral truth regarding the preservation or taking of innocent human life within the area of medical activity. The first of these — one is obliged to use every reasonable means to preserve human life recognizes human limitations and poses the non-absolute duty to pursue and promote human life. The second — one may never, for any reason, directly intend to take innocent human life — recognizes what is always in man's power, and absolutely forbids intentional acts of killing. The first principle makes possible the distinction made between extraordinary and ordinary means in the Church's discussion of medical-moral issues. It is this principle which allows us to recognize the fact that in certain instances an already dying patient may be allowed to die. The second principle forbids intentional acts of killing the innocent such as direct abortion, infanticide, murder, genocide, suicide and euthanasia. (Cf. Gaudium et Spes, 27,51) It should also be noted quite carefully that such intentional acts may involve either commission or omission, (Cf. Jura et Bona, Declaration on Euthanasia. II).
18.
A history of the tradition of ordinary and extraordinary means can be found in Daniel Cronin's The Moral Law in Regard to the Ordinary and Extraordinary Means of Conserving Life (Dissertatio ad lauream in Facilitate Theologica Pontificiae Universitatis Gregorianae), Rome, 1958, This work has been recently reprinted by Pope John Center, Braintree, MA under the title, Conserving Human Life, 1991.
19.
For a discussion of ordinary and extraordinary means see: Pope Pius XII, “The Prolongation of Life,”The Pope Speaks, 1958; O'Donnell op.cit., p. 55; Sacred Congregation for the Doctrine of the Faith, Jura et Bona, IV (Declaration on Euthanasia), 5 May 1980; Ashley and O'Rourke, op.cit., pp. 380-384. Although the terms “proportionate” and “disproportionate” are used in Jura et Bona, in place of “ordinary” and “extraordinary,” we agree with Ashley and O'Rourke that the terms ordinary and extraordinary “are as accurate as any other terms when used with a view to particular patients and with the realization that from an ethical perspective, they have a different meaning than when used from a medical perspective.” (Cf. Health Care Ethics, p. 382)
20.
The concept of “substituted judgment” comes into play when one is unable to make necessary decisions for oneself. This is clearly the situation in the case of the unconscious patient. Others (e.g., immediate family members, relatives, legal proxy, etc.) are asked to attempt to make the morally correct judgment that the unconscious person would have made, had this been possible. This does not imply that the judgment of the conscious person is simply set aside and the judgment of another person is accepted in its place. Rather, the purpose of the process is to consult with those who presumably would have the best knowledge and insight into what the patient would have desired had this judgment been within his present capacity. It should be quite evident, however, that the surrogate decision maker would not be making a correct moral judgment if he were to concur in a suicidal intent on the part of the now unconscious patient.
21.
Cf. Pope Pius XII, The Prolongation of Life op.cit. where he notes: “Normally one is held to use only ordinary means — according to the circumstances of persons, places, times and cultures — that is to say, means that do not invlove any grave burdens for oneself or for another.”
22.
It should be emphasized that in determining whether a particular means is ordinary or extraordinary one measures the benefits and burdens of the means for a particular patient. Therefore, the application of the principle is always “case specific.”
23.
Cf. Fred PlumM.D., “Artificial Provision of Nutrition and Hydration: Medical Description of the Levels of Consciousness,” in Critical Issues in Contemporary Health Care.Pope John Center, Braintree, MA, 1989, pp. 55–59. Cf. also Plum and Posner, op.cit., pp. 344-345. It should be pointed out, however, that there have been cases of recovery even after periods of years, as noted earlier.
24.
It should be noted that the use of feeding methods other than oral may sometimes be optional. Even when this is presented as needed for the “convenience” of the staff, it should not be assumed that this is necessarily meant in any self-centered way. Frequently enough, what is convenient for the staff also makes it possible to give each patient more overall attention and better care. It should also be noted, however, that a patient should not be put on optional methods of feeding other than oral, and then have the burdensomeness of these methods used as the excuse for discontinuing feeding altogether, even when it may be possible to return to oral feeding!
25.
Cf. Merck Manual, pp. 904–907.
26.
A standard method would be to introduce a catheter though the wall of the chest and into the vena cava. This is a much more serious process than we usually tend to imagine when we think of intravenous injection. This is, in fact, a surgical procedure and the proper placement of the catheter is verified by X-ray. Cf. Merck Manual, pp. 907–911.
27.
One example of this distinction can be found in The Report of PontificalAcademy of Sciences on the Artificial Prolongation of Life.1985. The text of this report may be found in Origins, December 5, 1985, and in Conserving Human Life. The Pope John Center, Braintree, MA, pp. 305-307. The document reads, in part: “By the term treatment the group understands all those medical interventions available and appropriate in a specific case, whatever the complexity of the techniques involved. If the patient is in a permanent, irreversible coma, as far as can be foreseen, treatment is not required, but all care should be lavished on him, including feeding. If it is clinically established that there is a possibility of recovery, treatment is required. If treatment is of no benefit to the patient, it may be interrupted while continuing with the care of the patient. By the term, “care,” the group understands ordinary help due to sick patients, such as compassion and spiritual and affective support due to every human being in danger.” Cf. also Jura et Bona, IV (Declaration on Euthanasia).
28.
The statement of the Pontifical Academy of Sciences is quoted in the preceding note. The statement of the Pontifical Council has this to say: “On the contrary, there remains the strict obligation to continue by all means those measures which are called ‘minimal,’ which are intended normally and customarily for the maintenance of life (alimentation [feeding], blood transfusions, injections, etc.). To interrupt these minimal measures would be equivalent, in practice, to wishing to put an end to the life of the patient.” (Quoted by Orville N. Griese in Conserving Human Life, p. 172.)
29.
What is said here about pain can be verified by reading such sources as: McQuillenMichael P.M.D., “Can People Who Are Unconscious or in the ‘Vegetative State’ Perceive Pain?” inIssues in Law and Medicine, Spring 1991, Vol. 6, No. 4, pp. 373–383; “Position of the American Academy of Neurology on Certain Aspects of the Care and Management of the Persistent Vegetative State Patient,” in Neurology, 125 (1989), quoted by Kevin O'Rourke, O.P., in “Should Nutrition and Hydration Be Provided to Permanently Unconscious and Other Mentally Disabled Persons?” in Issues in Law and Medicine, Fall 1989, Vol. 5, No. 2.; Council on Scientific Affairs and Council on Ethical and Judicial Affairs, “Persistent Vegetative State and the Decision to Withdraw or Withhold Life Support,” in JAMA, 263, January 19, 1990, pp. 426-429.
30.
Since there is no way in which we can enter into the mind of the patient who is unconscious, we cannot offer definitive statements about pain. Some authors would seem to indicate that there may be pain. For example, we read “Pain is a complex phenomenon, neither necessary nor sufficient to explain suffering. An analysis of the neuroscience of pain leads to the conclusion that pathways sufficient for the perception and modulation of pain need not rise nor descend to levels generally thought necessary for consciousness. Pain may be expressed not only in language, but also in autonomic and motor behavior that can be shown to correlate in a linear fashion with subjective pain sensation. Patients rendered unconscious by anesthesia, or who recover from traumatic coma, manifest memories of their time without consciousness. Although by definition the unconscious patient cannot tell you that he perceives pain, available data suggest that he may; therefore, you cannot know that he doesn't.” (McQuillen, op cit., p. 383.) Others, however, would hold that such pain is impossible (cf. Council on Scientific Affairs and Council on Ethical and Judicial Affairs, “Persistent Vegetative State and the Decision to Withdraw or Withhold Life Support,” in JAMA, 263, January 19, 1990.)
In the medical literature itself there is clear and growing evidence that even doctors are beginning to look at the killing of patients as an alternative to treating or caring for them. In one editorial piece in JAMA (259, January 8, 1988, p. 272, “It's Over, Debbie”), a doctor describes his own intentional killing of a suffering patient, who did not ask him to do this. In a special article in The New England Journal of Medicine (320, no. 13, pp. 844-849, “The Physician's Responsibility Toward Hopelessly III Patients”) ten of a group of twelve authors (all medical doctors) concluded that “it is not immoral for a physician to assist in the rational suicide of a terminally ill person.”
33.
Quoted by Everett KoopC.M.D., Sc.D., “Decisions at the End of Life,” in Issues inLaw and Medicine, Fall 1989, Vol. 5, No. 2, p. 226.
34.
Koop (op. cit., p. 227) quotes from Doctor Leo Alexander writing in the New England Journal of Medicine in 1948 in reference to the euthanasia program in Nazi Germany. Once any life was deemed worthy of not living, then it merely became a question of an authority which would determine just how many groups of people would eventually fit into that category. Alexander wrote: “This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, and finally all non-Germans, But it is important to realize that the infinitely small wedged-in lever from which this entire trend of mind received its impetus was the attitude toward the nonrehabilitable sick.”
35.
Council on Scientific Affairs and Council on Ethical and Judicial Affairs, “Persistent Vegetative State and the Decision to Withdraw or Withhold Life Support,” inJAMA, 263, January 19, 1990, p. 428.
36.
The supply of nutrition and hydration can rightly be judged an extraordinary means because of futility, for example, when death is imminent (provided it no longer serves even as a palliative); and in cases where the patient is unable to assimilate what is being supplied.
