A Catholic Perspective on the Ethics of Artificially Providing Food and Water

Paul John II 2004. This address was delivered to an international Congress Sponsored by the Pontifical Academy for Life and the World Federation of Catholic Medical Associations.

I have been told that the papal address was printed and delivered in Italian, and hastily translated by unknown staff. The doctrinal status of this papal statement is unclear. My colleague Father Himes casts doubt on the idea that it adds to “the official reaching of the Church,” noting that it was “one papal speech to a special audience… never promulgated to the universal church, nor were episcopal conferences ever told to revise their local hospital directives” to bring them into conformity with new teaching. (Himes, 2005, p. 8) If I am correct that the statement does not really advance what Himes characterizes as “a novel position” but only builds on, clarifies, and develops a more familiar ethical stance, then the issue is not crucial We should note, however, that in an age when even papal statements to local groups are quickly posted on the Vatican website in several translations, the distinction between private remarks and what is universally announced may no longer be so sharp.

See Ford, 2004.

Cahill claims the 2004 address is “marked by non sequiturs and inconsistencies.” immediately offering by way of illustration, “For one thing, it is hard to see how tube feeding can flatly be judged ‘not a medical act.”’ (Cahill, 2005, p. 16)

Cahill 2005, pp. 16–17.

Watt nicely makes a related point, while combating Father Ford's appeal to similarities between ANH and respirators. “Giving food and drink is… part of nonmedical, everyday care for many people, in a way that ‘oxygenating’ people is (at least after birth). Infants and toddlers are routinely spoon-fed, as are disabled people of all ages. Tube-feeding is a low-tech extension of this kind of assistance: like the use of catheters, it is basic nursing care… In any case, PVS patients often retain some ability to swallow, so that spoon-feeding would presumably need to replace the more convenient tube-feeding if that were withdrawn.” (Watt, 2004; contrast Ford, 2004: “Both [ANH and respirators], after all, use a medical procedure; in both cases death is the natural outcome unless ventilation or MANH is continued. Air and food are equally necessary for the maintenance of spontaneous life. If the ventilator may be ethically withdrawn, why not also MANH?”)

Australia's bishops suggested this in Australian Conference of Catholic Bishops, 2003.

Never permitted, except in the situation described in the following paragraph where ANH does not achieve its “proper finality” of nourishing the patient and therein palliating her discomfort.

The consensus statement issued on this document by a 2004 Colloquium of the Canadian Catholic Bioethics Institute stresses this. The signatories affirm: “The papal speech needs to be understood in the context of the Catholic tradition. The words in principle’ (in the passage cited) do not mean ‘absolute’ in the sense of ‘exceptionless’ but allow consideration of other duties that might apply,” Their proposed gloss on the pope's statement seems to me well crafted and reasonable: “For unresponsive patients to whom ANH can be delivered without being in itself in conflict with other grave responsibilities or overly burdensome, costly or otherwise complicated, ANH should be considered ordinary and proportionate, and, as such, morally obligatory.” They continue, “Treatments cannot be classified ahead of tine as (inherently) ordinary or extraordinary. Reference must be made to the wishes and values of the patient, his or her condition, and the availability of health care in the given context… Extraordinary treatments are those that do involve excessive pain, expense, or other burdens.” That determination is situation-based. (Canadian Catholic Bioethics Institute, 2004, para. 5, 7). In contrast. Cahill too confidently asserts that “the (papal) speech is not consistent with prior well-established papal teaching.” (Cahill, 2005, p. 17) I seek a reading of the allocution that enables us to resist that extreme and implausible judgment.

See National Catholic Bioethics Center, 2005.

I say that PVS only “may rule out the patient's experiencing pain” because the matter has been controverted. Ford reports that the Congress to whom the pope made his March 2004 remarks also “heard evidence that some PVS patients had minimal consciousness, and that there was a possibility they could experience pain.” As Ford notes, if and insofar as she can experience discomfort, the possibility is raised that ANH may be morally optional, discretionary, for a PVS patient on the grounds that the pain it causes her constitutes an excessive burden. (Ford, 2004) My point is that, even in the absence of any possibility of pain, considerations of ANH's excessive and disproportionate burden may come into play because of the expense it runs the patient, her family, or others. In the last sections of this essay. I raise some ethical worries properly arising from recent theorists’ emphasis on the social cost of sustaining life.

See United States Conference of Catholic Bishops, 2001.

Ford 2004. A joint statement from the International Congress that the pope addressed describes a vegetative state as “a stale of unresponsiveness, currently defined as a condition marked by: a state of vigilance, some alternation of sleep/wake cycles, absence of signs of awareness of self and surroundings, lack of behavioural responses to stimuli from the environment, (and) maintenance of autonomic and other brain functions.” (International Congress, 2004, para. 1) What is important for our purposes is that characterizing the state in this way, chiefly by observed operations and (lack of) responses, leaves open the possibility that such a patient may experience pain in her inner life though she does not manifest typical behavior.

To say this is not necessarily to endorse the confused counterfactuals that muddle much of today's debate. Plainly, there can be little sense to questions about what the PVS patient “would have wan led.” This subjunctive indicates that the desire is conditioned on some situation. But what could it be? It is laughable to inquire whether she would or would not want (like?) being in PVS if she were in that condition (of a lack of awareness) and aware of it. Is it, then, that what matters is whether she would opt for a PVS life if described to her? But why should such a preference, essentially uninformed by any experience, be what counts?

Bailey quotes a definition according to which “a particular medical treatment (is) futile if that treatment is incapable of accomplishing any of the specific goals of treatment.” (Bailey, 2004, pp. 78-79) The “any” here is supposed to eliminate subjective judgments but, as Bailey sees, the account remains problematic. If the definition is meant to pick out only such treatments as undeniably have no chance of accomplishing any of their goals to any extent, it is so narrow as to have almost no application. If it is meant less restrictively, then room remains for judgments of likelihood and assessments of evidence. “(I)t will be rare, if not impossible, that the evidence will demonstrate that the particular intervention to be (sic) ineffective 100% of the time. What if statistical evidence shows that a particular intervention will succeed in achieving its goal 1% of the time? Strictly speaking, this intervention cannot then be labeled physiologically futile.” (Bailey, 2004, p. 80)

Here I draw on the account offered in Schneiderman and Capron as amended by Bailey and further modified. (See Schneiderman and (“apron, 2000, and Bailey, 2004) I depart from Bailey, however, in holding that what matters for a (somatic) treatment's futility or efficacy is not whether it achieves its overall goal of effecting the patient's recovery but whether it makes the (causally) more immediate and smaller-scale physiological changes that it is hoped will contribute to her recovery.

“Health care professionals may be confronted by patients who, with suicidal wishes, refuse ordinary life-sustaining care. Such patients must be treated with concern for their dignity and well-being. Health care professionals should do their best to protect the life and health or the patient while recognizing there may be legal and professional limits to their ability to intervene… (Nevertheless, a) Catholic health care professional should not cooperate in implementing a suicidal directive.” (Canadian Catholic Bioethics Institute, 2004, para. 12, 20),

There are, thus, innocent mistakes that the patient might make, overestimating the suffering a treatment will cause (or its probability). Such failings in judging and reasoning are not normally culpable, even when born of emotional distortions, such as fear. Of course, controllable but uncontrolled, tear, when excessive (or insufficient), can be a type of moral vice that can morally contaminate the judgments and decisions it shapes. Further, the patient may judge treatment too burdensome simply because she viciously despises a life of dependency, counting it as no benefit at all. Not all mistakes, then, about whether a mode of treatment's costs are too great, will be innocent. I am grateful to Prof. Tollefsen for turning my attention to some of these points.

Pinker 1497. Pinker does not specify which are “the moral philosophers” who root human rights in what “happens” to be true of us but, unfortunately, there is no shortage of such thinkers who deny to humanity inherent dignity and restrict rights to those who have reached a certain level of development and accomplishment

Smoker 2003

Lagerkrantz 2004.

Keizer 2005, p. 55.

Keizer 2005, p. r61

Keizer 2005, p. r52

Robertson 2004, p. 36.

Robertson 2004, p. 37.

Montagne 2004.

See MacIniyre 1999.

Counter 2005, p. El.

Counter 2005, p. E2.

Gillick 2000, p. 209.

The Canadian statement pertinently reminds us that “Some restraints may constitute an assault on human dignity… Restraints can also lead to complications such as pressure sores.” (Canadian Catholic Bioethics Institutes, 2004, para. 15).

For the controversy, see Vollmann , 2000.

The Canadian statement is again helpful on this point. “While recognizing that it is impossible to place monetary value on human life, the cost of treatment can be a morally relevant factor in health care decisions, especially if patients or their families have to bear the entire economic burden.” (Canadian Catholic Bioethics Institute, 2004, para. 9).

USCCB, 2001.

Orr , and Meilander 2004.

Ford 2004. Similarly, Cahill is careful to distance herself from those who claim “that continued life would be a benefit no matter what its condition.” and maintains that “it could reasonably be argued that 15 or more years of existence in a ”vegetative” state neither serves human dignity nor presents a fate that most reasonable people would obviously prefer to death.” (Cahill, 2005, pp. 16, 17) I think it incoherent to deny that life is always a benefit to a human being and can discern no disservice to human dignity in preserving a human life, in which dignity inheres as such and irrespective of the blocking of many normal capacities. On the contrary, to deem such a life as beneath preservation is to deny its inherent status. Whether many reasonable people would prefer death to a long life in PVS is morally irrelevant, since they may seek escape in death out of despair and incomprehension before the prospect of such a limited existence. Even reasonable people, of course, form some preferences from irrational parts of the self. Cahill suggests the chief issue is whether John Paul II's 2004 allocution Settl(es) the question in favor of always using artificial nutrition.” However, this threatens to mislead. She herself notes that Richard Doerflinger, a spokesperson for the U.S. bishops on pro-life matters, denies that the statement “declared an absolute moral obligation to provide assisted feeding in all cases,” (Cahill, 2004, pp. 16, 17; emphasis added) The papal statement explicitly repudiates ANH in cases where it is ineffective. Rather, the controversy today is, as Father Ford puts it, over the range of remaining discretion, what “wriggle room is now left for doctors in Catholic hospitals to continue to make decisions (about ANH for PVS patients) on a case-by-case basis.” (Ford, 2004)

Orr , and Meilander 2004.

For one such reference to our “anti-life culture,” see John Paul II's 1981 Apostlic Exhortation, Familiaris Consortio, sec. 30. For “anti-culture,” see his 1984 Address to the Pontifical Council for Culture, cited at Dulles, 1999, p. 123.

Australian Conference of Catholic Bishops, “Briefing Note on the Obligation to Provide Nutrition and Hydration.” Available at www.ache.catho1ic.org-au/pdf/040903briefingnote.pdf.

Bailey Susan “The Concept of Futility in Health Care Decision Making.” Nursing Ethics 11 (2004): 77–83.

Cahill Lisa Sowle “Catholicism, Death and Modern Medicine.” America, April 25, 2005, pp. 14–17.

Canadian Catholic Bioethics Institute. “Reflection on Artificial Nutrition and Hydration.” consensus statement of a Canadian Catholic Bioethics Institute colloquium in Toronto, June 14-17, 2005.

Counter S. Allan Dr. “Music Stirred Her Damaged Brain.” Boston Globe. March 29, 2005, pp. E1–E2.

Dulles , Avery S.J. The Splendor of Faith. New York, Crossroad, 1999.

Ford Norman “Impacts of Papal Teaching on Vegetative Patients in Catholic Hospitals.” Available at the Australian website. Onlineopinion.com.au/print.asp?article=2219 Originally published in The Tablet, 1 May 2004.

Muriel Gillick M.D. “Rethinking the Role of Tube Feeding in Patients with Advanced Dementia.” New England Journal of Medicine. Vol. 342, no. 3 (January 20, 2000): 206–210.

Himes , Kenneth O.F.M. “To Inspire and Inform.” America, June 6-13, 2005, pp. 7–10.

International Congress on Life-Sustaining treatments and Vegetative State: Scientific Advances and Ethical Dilemmas. “Joint Statement.” March 10-17, 2004.

Paul John II “Address to Participants in an International Congress on Life-Sustaining Treatments and Vegetative State.” March 20, 2004.

Keizer Garret “Life Everlasting.” Harper's. February 2005, pp. 53–61.

Lagerkrantz H. “Should Euthanasia Be Legal?” Archives of Disease in Childhood. Fetal and Neonatal Edition. 89 (January, 2004): p. F2.

MacIntyre Alasdair Dependent Rational Animals: Why Human Beings Need the Virtues. London: Duckworth, 1999.

Montague Renée “Interview with Dr. Eduard Verhagen.” National Public Radio, December 1, 2004.

National Catholic Bioethics Center. “The Case of Terry Schiavo.” Press release of March 18, 2005 available at nebcenter.org/press/05-03-18-Schiavo.html.

Orr Robert , and Meilander Gilbert “Ethics and Life's Ending: An Exchange.” First Things 145 (August/September 2004): 31–37.

Pinker Stephen “Why They Kill Their Newborns.” New York Times, November 2, 1997.

John Robertson “Extreme Prematurity and Parental Rights After Baby Doe.” Hastings Center Report July-August 2004, pp. 32–39.

Smoker Barbara “On Advocating Infant Euthanasia.” (Op-Ed) Free Inquiry 24 (December 2003): pp. 17–18.

United States Conference of Catholic Bishops. “Ethical and Religious Directives for Catholic Health Care Services.” fourth edition. Washington: United States Conference of Catholic Bishops, 2001.

Watt Helen “In Defense of Just being.” Available at the Australian website: Onlineopinion.com.au/print.asp?article=2294, Originally published in The Tablet, 1 May 2004.