Artificial Nutrition and Hydration: It Is Time to Take a Stand
• Artificial nutrition and Hydration (ANH), a title used more by moralists than by nutritionists, refers to several methods of feeding patients when oral feedings are not possible for one reason or another. ANH includes enteral feeding, in which the food is introduced into the gastro-intestinal tract through a tube inserted in the nose or mouth, or directly into the stomach. ANH also includes parenteral feeding, which refers to the introduction of food where the patient cannot take in nourishment through the gastro-intestinal tract. Then another form of ANH, intravenous feeding (IV) is used. When IV is needed for a longer period, the feeding is carried out through a larger central vein. This is called total parenteral nutrition (TPN). This is a special surgical procedure which requires a team of specialists.1
Moral questions concerning ANH deal primarily with the obligation of using enteral feeding and the criteria for discontinuing its use for particular patients. These moral questions are also legal questions being debated in varying states2 The most pressing problem concerns ANH for people in a comatose state.
As with any moral problem, the first and most important step is to determine what methodology should be used in reaching a judgment. Here it is possible to distinguish earlier Catholic positions, more contemporary Catholic positions, and contemporary non-Catholic positions.
In the 1940s and 1950s, the principal Catholic moral theologians in the United States were Gerald Kelly, S.J.,3 John C. Ford, S.J., and Francis J. Connell, C.Ss.R. Father Kelly's book Medico-Moral Problems was a collection of answers to cases which had been proposed to him. The answers were based on natural law thinking, as interpreted with the help of Church documents.
In the 1970s and 1980s, medical advances presented new moral problems. The earlier period of fundamental consensus among theologians, even with disagreements on particular issues, began to break down. Some of the moralists continued to reach their judgments through the application of natural law principles. Others, called proportionalists, focus on the consequences of acts and the proportion between good and evil effects in reaching decisions. One often includes in the former group moralists such as Msgr. William Smith and Professor Germain Grisez. In the latter group are often included moralists such as Richard McCormick, S.J. and Bernard Haring.
Until fairly recently, diocesan and Catholic hospital policy on ANH was usually influenced by Catholic moralists, whether traditional or proportionalist.
In the most recent period, even in Catholic colleges and universities, the discussion of moral problems has moved away from both these positions of Catholic theologians. New methodologies developed by secular bioethicists may be described as principled ethics, virtue ethics, casuistry, and legal or political ethics.
The most important text of principled ethics is the work of Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics.4 This work organizes the materials around four principles: autonomy, non-maleficence, beneficence, and justice. ANH is treated by the authors under the principle of non-maleficence.5
A contemporary attempt to build virtue ethics, or an ethics of the good, is that of Raymond J. Devettere.6 This author draws from Aristotle the first principle of ethics that people seek their good, the goal we all naturally seek, "to live well, to live a good life, to achieve fulfillment, to flourish, to be happy while we live." Devettere holds that there is no way to resolve the difference of opinion about whether happiness can occur only in this life or whether it can occur in a life after death. Each person is left with an individual choice here. "For our purposes, it makes no difference which option is embraced, for both are compatible with the ethics we develop in this book."7 In other words, God and immortality are not significant in reaching ethical decisions.
A major new non-religious approach to ethics, attempting to pull over its shoulders an ecclesiastical cassock, is "casuistry." The professors of this approach are Albert R. Jonsen, a former Jesuit priest, and Stephen Toulmin.8 For the new casuists, the core of moral knowledge is not found in accepting universal propositions such as "cruelty is wrong." Rather, moral knowledge consists in the ability to put our moral discernment to work. It is not a matter of applying ethical principles to particular cases. Instead, it is a matter of our affective sensibility. The resolution of moral problems depends more on the practical understanding of concrete cases than it does on the theoretical grasp of abstract connections.9
A fairly new development of medical ethics is that proposed by Ezekiel Emanuel. Beauchamp and Childress describe Emmanuel's vision of medical ethics as a "Moderate communitarianism."10 Emanuel holds that the ends of medicine are shaped by public laws and public values, and that medical ethics should be seen as related to political theory rather than theology or philosophy. A similar position is held by Albert R. Jonsen, Robert M. Veatch and LeRoy Walters in their documentary history of bioethical public policy documents and decisions.11 These laws and judicial decisions have often been pivotal in defining bioethical issues and in determining ways of managing them. This means in effect that ethical decisions concerning health care are reached on the basis of judicial decisions and on an ethics of consensus, a kind of least common denominator morality. It is interesting to note that the collection of documents, a book of five hundred and ten pages, contains only one document from a Catholic source, the Instruction on Respect for Human Life by the Congregation for the Doctrine of the Faith, February 22, 1987. The Ethical and Religious Directives for Catholic Health Care Services, of the National Conference of Catholic Bishops, is not included in this book published by the Georgetown University Press, the publishing arm of a Catholic university.
In summary, it seems clear that the discussions and debates about the basis for discussions in bioethics, including decisions about artificial nutrition and hydration, have to a great extent moved away from the earlier discussions among Catholics. During that earlier period, secular writers would often neglect the Catholic theologians who tried to remain faithful to the doctrine of the Magisterium of the Catholic Church, but occasionally they cited writers such as Bernard Haring, Charles Curran, and Richard McCormick. At the present time, many of the secular writers do not refer to even the more liberal Catholic moralists, let alone to the Ethical and Religious Directives for Catholic Health Care Services.12
While it is clear that the arguments used by these non-Catholic ethicians will have to be evaluated, that evaluation will have to be made in the light of the great ethical principles clearly taught by Sacred Scripture and by the Church's Sacred Tradition, as discerned by the Magisterium of the Church.
This treatment of the moral aspect of artificial nutrition and hydration is being developed within the framework of Catholic theology. It will be helpful therefore to list the principal Catholic doctrinal statements which deal with this subject. The Congregation for the Doctrine of the Faith issued the Declaration of Euthanasia on May 5, 1980.13 This document is very helpful in bringing out the value of human life. The declaration states clearly:
No one can make an attempt on the life of an innocent person without opposing God's love for that person, without violating a fundamental right, and, therefore, without committing a crime of the utmost gravity.14
This principle is then nuanced by the declaration when it speaks of due proportion in the use of remedies.
Today it is very important to protect, at the moment of death, both the dignity of the human person and the Christian concept of person against a technological attitude that threatens to become an abuse. . . . The use of therapeutic means can sometimes cause problems.15
The declaration points out that in numerous cases the complexity of the situation can be such as to cause doubts about the way ethical principles should be applied. In the past, the means were described as "ordinary" or "extraordinary," and the principle was that one is never obliged to use extraordinary means. The declaration holds that the principle still holds good, but is perhaps less clear today by reason of the imprecision of the terms "ordinary" and "extraordinary" and the rapid progress made in the treatment of sickness. The Congregation, therefore, points out that some prefer to speak of "proportionate" and "disproportionate" means. One may legitimately wish "to avoid the application of a medical procedure disproportionate to the results that can be expected. . . ."16 The Congregation then states:
When inevitable death is imminent in spite of the means used, it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted.17
Bioethicists have interpreted this paragraph in two different ways. Some have described artificial nutrition and hydration as a medical treatment which in certain cases may be discontinued. Others, including the present writer, have interpreted the words "normal care" as including the provision of nourishment, even if done through a gastric tube.
In 1992, the National Conference of Catholic Bishops Committee for Pro-Life Activities prepared a resource paper on Nutrition and Hydration: Moral and Pastoral Reflections.18 The paper has a helpful appendix on the technical aspects of medically assisted nutrition and hydration. This appendix distinguishes between the medical aspects of parenteral or intravenous feeding and enteral tube feeding. Peripheral intravenous lines can maintain fluid balance and prevent dehydration, but they cannot provide adequate nutrition in the long term. Total parenteral feeding, using a larger needle inserted into a central vein near the heart, can provide a more adequate nutritional balance, but poses significant risks to the patient, and may involve costs much greater than other methods of feeding. This has become a mainstay for helping critically ill patients to survive acute illnesses, but its feasibility for long term maintenance of patients is questionable. Enteral tube feeding is the focus of the current moral debate over medically assisted nutrition and hydration. The tube may be introduced through the nasal cavity or inserted through the abdominal wall into the stomach or small intestine. The observations of the bishops' committee and of this paper deal especially with enteral tube feeding.
The bishops' committee points out as a fundamental principle of morality that all crimes against life, including euthanasia or suicide, must be opposed. Suffering is presented as of special significance for the Christian as an opportunity to share in Christ's redemptive suffering. Nevertheless, it is a positive good to relieve a patient's suffering as long as one does not intentionally cause death or interfere with other moral or religious duties. One is not obliged, however, to use means which are extraordinary or disproportionate in preserving life. In the final stage of dying, when inevitable death is imminent in spite of the means used, one may refuse forms of treatment that would only secure a burdensome prolongation of life or which would only prolong the process of dying. In such cases, the normal care due to a sick person should not be interrupted. Further reference will be made to this important document later in this paper.
The next document of importance is this discussion is the 1994 text of the Ethical and Religious Directives for Catholic Health Care Services. The directives indicate that there are moral issues which have not been definitively resolved by the Magisterium of the Church, for example, the morality of withdrawing medically assisted hydration and nutrition from a person who is in a "persistent vegetative state." This paper is meant to support a position in that debate. The directives (58) indicate that there should be a presumption in favor of providing nutrition and hydration to all patients as long as this is of sufficient benefit to outweigh the burdens involved to the patient.
A document of Pope John Paul II that is helpful in this discussion about artificial nutrition and hydration is the 1993 encyclical The Splendor of Truth. This encyclical upholds the traditional teaching that the primary and decisive element for moral judgment is the object of the human act. The consideration of the intention is not sufficient. It is not licit to do evil that good may come of it (see Romans 3:8). Our Holy Father, Pope John Paul II, gave us another helpful encyclical in 1995, The Gospel of Life. In this encyclical there are three moral teachings which have to be accepted with divine faith. The first of these is that "The direct and voluntary killing of an innocent human being is always gravely immoral" (57). The second is that "direct abortion, that is, abortion willed as an end or as a means, always constitutes a grave moral disorder" (62). The third teaching is that "euthanasia is a grave violation of the law of God." The Gospel of Life is one of the most important messages delivered by our Holy Father. It states clearly the terms of the struggle now taking place between the Culture of Life and the Culture of Death.
A recent Catholic document that can be helpful in this discussion is The Charter for Health Care Workers issued by the Pontifical Council for Pastoral Assistance to Health Care Workers. The first edition was issued in October 1994. Reference here is made to the fourth edition, issued in May 1995, and updated in conformity with the encyclical The Gospel of Life. In that document it is taught that "The administration of foods and liquids even artificially is part of the normal treatment always due to the patient when this is not burdensome for him. Their undue suspension could be really and properly called euthanasia."19
The position of the NCCB committee received another strong support on October 2, 1998, when Pope John Paul II spoke to the bishops from California, Nevada and Hawaii, who were making their ad limina visits to Rome. The Holy Father told the bishops that the pro-life movement is one of the most positive aspects of American public life, and the support given it by the bishops is a tribute to their pastoral leadership. After pointing out that there are "signs of an almost unimaginable insensitivity to the reality of what actually happens during an abortion," the Holy Father pointed to this as a cause for deep concern. "A society with a diminished sense of the value of human life at its earliest stages has already opened the door to a culture of death." The Holy Father then pointed out that euthanasia and suicide are grave violations of God's law, referring to The Gospel of Life nos. 3, 55 and 56. The Holy Father encouraged Catholics to continue working with members of other Christian communities to resist efforts to legalize physician-assisted suicide. He urged the bishops to build an even broader ecumenical and inter-religious movement in defense of the culture of life and the civilization of love. The Pope told the bishops that, "As ecumenical witness in defense of life develops, 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, what the Catechism of the Catholic Church calls "the refusal of over-zealous treatment"20—and taking away the ordinary means of preserving life, such as feeding, hydration, and normal medical care. The statement of the US Bishops' Pro-Life Committee, Nutrition and Hydration: Moral and Pastoral Considerations, rightly emphasizes that the omission of nutrition and hydration in order to cause a patient's death must be rejected and that, while giving careful consideration to all the factors involved, the presumption should be in favor of providing medically assisted nutrition and hydration to all patients who need them.21
The most fundamental principle governing the morality of nutrition and hydration is that taught by Pope John Paul II in The Gospel of Life—the absolute inviolability of innocent human life. This principle has been preserved in the Church by the presence of the Holy Spirit who safeguards the people of God from error in matters of faith and morals. This teaching is an expression of good medicine, and is accepted by most doctors. It was endorsed by the House of Delegates of the American Medical Association on December 4, 1973:
The intentional termination of the life of one human being by another—mercy killing—is contrary to that for which the medical profession stands and is contrary to the policy of the American Medical Association.22
While authors such as James Rachels have tried to make a case against the distinction between active killing and allowing to die, the clear teaching of Pope John Paul II in The Gospel of Life is the strongest possible theological argument against that attempt: "the direct and voluntary killing of an innocent human being is always gravely immoral" (57). The deliberate decision to deprive an innocent human being of his life is always morally evil and can never be licit, either as an end in itself or as a means to a good end. It is, in fact, a grave act of disobedience to the moral law, and indeed to God himself, the author and guarantor of the law. The Holy Father (no. 57) then quotes the 1980 Declaration on Euthanasia of the Congregation for the Doctrine of the Faith:
Nothing and no one can in any way permit the killing of an innocent human being, whether a fetus, or embryo, or an adult, or an old person, or one suffering from an incurable disease, or a person who is dying. Furthermore, no one is permitted to ask for this act of killing either for himself or herself or for another person entrusted to his or her care. Nor can he or she consent to it either explicitly or implicitly. Nor can any authority legitimately recommend or permit such an action.
In The Gospel of Life, Pope John Paul II establishes the principles for a correct moral judgment on euthanasia. First he provides a clear definition:
Euthanasia in the strict sense is understood to be an action or omission which of itself and by intention causes death with the purpose of eliminating all suffering. (65)
The Holy Father then distinguishes euthanasia from the decision to forego aggressive medical treatment, that is: medical procedures which no longer correspond to the real situation of the patient, either because they are by now disproportionate to any expected results or because they impose an excessive burden on the patient or his family. In such situation, when death is clearly imminent and inevitable, one can in conscience "refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted" (65).
It is important to note that the Holy Father's treatment in The Gospel of Life is expressed in the language of the 1980 Instruction of the Congregation for the Doctrine of the Faith. The inclusion of the language of the Instruction in the encyclical provides the Instruction with a much higher authority.
Even before determining whether such treatment is a medical procedure or normal care, artificial nutrition and hydration would not be required when death is clearly imminent and inevitable. The question is, may one discontinue ANH for a person who is not in the process of dying?
With regard to that latter question, it is helpful in interpreting the words of the Congregation for the Doctrine of the Faith, and therefore of the Holy Father, to recall that, in the preparation of the 1994 Ethical and Religious Directives, the Committee on Doctrine of the National Conference of Catholic Bishops was in direct consultation with the Congregation for the Doctrine of the Faith with regard to the wording of its statement on artificial nutrition and hydration. The committee had originally proposed merely to refer to the various statements expressed by state bishops' conferences in the United States, statements which disagree on this question. The Congregation asked that the Directives give special prominence to the 1992 statement of the NCCB Committee on Pro-Life Activities.
Drawing upon the committee statement, the Directives point out the distinction
between questions already resolved by the magisterium and those requiring further reflection, as, for example, the morality of withdrawing medically assisted hydration and nutrition from a person who is in the condition which is recognized by physicians as "the Persistent Vegetative State (PVS)."23
The Committee for Pro-Life Activities statement points out that our Catholic Tradition does not demand heroic measures in fulfilling the obligation to sustain life.
A person may legitimately refuse even procedures that effectively prolong life if he or she believes that they would impose excessively grave burdens on himself or herself, or on his or her family and community.24
The NCCB Committee then quotes the very important article "Feeding and Hydrating the Permanently Unconscious and other Vulnerable Persons," by William E. May, and a group of associates.25
Catholic theologians have traditionally viewed medical treatment as excessively burdensome if it is "too painful, too damaging to the patient's bodily self and functions, too psychologically repugnant to the patient's liberty and preferred activities, too suppressive of the patient's mental life, or too expensive."26
In interpreting the NCCB statement, it is helpful to refer to this article by William E. May and associates. A very important point which they make is that deliberately to deny food and water to an innocent human being in order to bring about that person's death is homicide. 27 This, of course, is contrary to the teaching of The Gospel of Life concerning the absolute inviolability of innocent human life. 28 May, et al. draw the implications of this principle:
It is never right and ought never to be legally permitted to withhold food and fluids from the permanently unconscious or from others who are seriously debilitated, (e.g. with strokes, Alzheimer's disease, Lou Gehrig's disease, organic brain syndrome, or A.I.D.S. dementia), as a means of securing their deaths.29
In some situations, however, the withholding and withdrawing of artificial nutrition and hydration is not intended as a means of death. May and his associates hold that:
One may rightfully choose to withhold or withdraw a means of preserving life if the means employed is judged either useless or excessively burdensome. It is most necessary to note that the judgment made here is not that the person's life is useless or excessively burdensome.30
Examples of cases where a treatment is useless or excessively burdensome include the case of a person who is imminently dying, and the case of a person who is no longer able to assimilate the nourishment or fluids thus provided.31 In addition to the physical burden of ANH, there may be psychological burdens on the patient. Here the NCCB committee notes that:
One should distinguish between repugnance to a particular procedure and repugnance to life itself.32
With regard to a possibility of foregoing ANH because of excessive expense,33 William May and his associates point out that the cost of providing food and fluids by enteral tubes is not, in itself, excessive.
Such feeding is generally no more costly that other forms of nursing care (such as cleaning or spoon feeding a patient) or ordinary maintenance care (such as the maintenance of room temperature through heating or air conditioning).34
With these principles in mind, it is helpful to consider several court decisions. The first is In the Matter of Claire Conroy, before the Supreme Court of the State of New Jersey.35 The court held that the withholding or withdrawing of life-sustaining treatment was justified. In this decision the Supreme Court rejected the decision of the court of second instance, the Appellate Division, which distinguished between the providing of nutrition and hydration and treatment aimed at curing a disease. It is astonishing that on this key point the court did not attempt to explain its rejection of the Appellate Division's position. Unfortunately, the court introduced into its decision reference to the testimony of a Catholic priest, who also, it seems, did not understand the significance of this distinction.36
A second major case involving refusal of nutrition and hydration involved Nancy Beth Cruzan, a young accident victim who was being fed with a gastrostomy.37 This is the only case involving the withdrawal of ANH that went to the United States Supreme Court. The court of first instance in Missouri authorized the withdrawal of ANH on the basis of statements made to a room-mate about a year before the accident. The Missouri Supreme Court reversed this decision. It said that medical nutrition cannot be withdrawn from a patient in a permanent vegetative state (PVS) unless there was clear and convincing evidence that this was the patient's wish. The court noted correctly that Nancy was not terminally ill and was not suffering. The decision was based on a strict interpretation of the doctrine of informed consent, which gives people a right to refuse treatment. The case finally reached the United States Supreme Court, and the court decided, in June 1990, that the State of Missouri's insistence on clear and convincing evidence before a proxy could have a feeding tube removed did not violate the Constitution. In other words, the court affirmed the decision of the Missouri Supreme Court that ANH could not be withdrawn. Nevertheless, after the United States Supreme Court's decision, the parents of Nancy Cruzan went back to the court of first instance where three friends of Nancy gave clear and convincing testimony that she would never want to live in a PVS state. The Supreme Court of Missouri was no longer involved in the case. It is important to note that the decision in this case does not distinguish between ANH and other methods of sustaining life.
The most important article within a Catholic perspective for withdrawing ANH is that of Thomas A. Shannon and James A. Walter.38 They are careful to point out that the moral intention to forego or withdraw ANH is not identical with the intention of euthanasia. The intention to bring about the death of the patient would be immoral. Secondly, they present their position as a moral option, not as a mandatory practice. This is in view of the lack of consensus among theologians. One unfortunate failure in this article is the failure to distinguish between ANH and life saving technology such as the use of a ventilator. It is significant that, when the use of a ventilator is withdrawn, the cause of death is the disease which makes it difficult to breathe. When ANH is withdrawn, on the other hand, it seems duplicitous to say that the cause of death is the illness. The person has died of starvation, a person who would be alive if fed. With regard to the arguments of those in favor of removing ANH from people in a comatose condition, it is possible to evaluate their positions by the clear standards established by the ecclesiastical documents. It is gravely immoral to intend directly the death of any patient for whatever reasons. To be acceptable theologically, casuistry has to be based on theological principles which are then applied to individual cases. Judicial decisions and governmental reports do not allow one to contravene moral principles; in addition, moral teachings can only be understood correctly within a transcendental horizon where they are significant before God and bound up intimately with the question of eternal salvation. The secular bioethicists do not stand up before theological examination.
After surveying some of the most important legal and ethical positions with regard to withholding or withdrawing of ANH, it is now appropriate to sum up what I may call a pro-life position.
1. First of all it is gravely immoral directly to destroy an innocent human life.
2. Euthanasia is understood as any action or omission which of itself or by intention causes death, with the purpose of eliminating all suffering. Euthanasia is a grave violation of the law of God.
3. To withhold or withdraw ANH with the intention of bringing about the patient's death is direct killing and is gravely immoral.
4. Even in cases where one may legitimately withdraw technology, such as a ventilator, one may not on the same grounds withdraw ANH.
5. Since the purpose of ANH is not to effect a cure but rather to keep the person alive by providing nutrition, one may not withdraw ANH on the basis that it is ineffective if, in fact, it does keep the patient alive.
6. When ANH would be ineffective, for example, when death is imminent whether the person receives nourishment or not, or when the patient cannot digest food introduced into the stomach or intestines, one may legitimately withhold ANH on the ground that it is ineffective.
7. The fact that the patient may be in a comatose condition is not morally significant in determining whether or not to provide ANH.
The bishops of the United States in the Ethical and Religious Directives have pointed out that there are questions requiring further reflection, as, for example, the morality of withdrawing medically assisted hydration and nutrition from a person who is in "permanent vegetative state" (PVS). 39 The bishops cite their Committee for Pro-Life Activities for this position. In the light of the evidence available concerning this question, it is now time to declare that the period of further reflection is ended, and that assisted nutrition and hydration should be provided to all patients, except in those cases where ANH would not be effective in sustaining life. After surveying the literature on this question, it is also clear that greater efforts have to be made to use the Catholic documents such as the Ethical and Religious Directives, the NCCB Pro-Life Committee statement on nutrition and hydration, and the two great encyclicals of John Paul II, The Splendor of Truth and The Gospel of Life, in programs to teach bioethics to all Catholic doctors, nurses and other health care professionals. In particular, this should be part of the effort to restore Catholic identity to Catholic colleges and universities, as demanded by the Apostolic Constitution Ex Corde Ecclesiae. This should be insisted upon especially for the publishing houses sponsored by Catholic universities and religious communities (39).
It would seem that, in the culture war between the Culture of Death and the Civilization of Life, no one may stand on the side lines.40 •
Endnotes
1 Sue Rodwell Williams, Basic Nutrition and Diet Therapy, (10th Ed.) (St. Louis: Mosby, 1995) 329f.
2 The New York State Task Force on Life and Law, Life Sustaining Treatment: Making Decisions and Appointing a Health Care Agent (New York State Task Force on Life and the Law, 1987).
3 Gerald Kelly, S.J., Medico-Moral Problems, (St. Louis, Missouri: The Catholic Hospital Association, 1958).
4 Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics. (4th Ed.), (New York: Oxford University Press, 1994).
5 Beauchamp and Childress, pp. 202-206.
6 Raymond J. Devettere, Practical Decision Making in Health Care Ethics: Cases and Concepts, (Washington, DC: Georgetown University Press, 1995).
7 Devettere, p. 32.
8 Albert R. Jonsen and Stephen Toulmin, The Abuse of Casuistry: A History of Moral Reasoning, (Berkeley: University of California Press, 1988). See also Albert R. Jonsen, The New Medicine and the Old Ethics, (Cambridge Mass: Harvard University Press, 1990).
9 Jonsen and Toulmin, p. 331.
10 Beauchamp and Childress, p. 83. See Ezekiel J. Emanuel, The End of Human Life: Medical Ethics in a Liberal Policy, (Cambridge, Massachusetts: Harvard University Press, 1991).
11 Albert R. Jonsen, Robert M. Veatch, LeRoy Walters, Source Book in Bioethics, (Washington DC: Georgetown University Press, 1998). See also Amy Gutman and Fenis Thompson, "Deliberating about Bioethics," Hastings Center Report 27, no. 3 (1997), 38-41 for a conception known as "deliberative democracy."
12 National Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, (Washington DC: US Catholic Conference, 1995).
13 See Thomas J. O'Donnell, S.J., Medicine and Christian Morality, (3rd ed.), (New York: Alba House, 1996) pp. 327-335.
14 O'Donnell, p. 329.
15 O'Donnell, p. 332.
16 O'Donnell, p. 333.
17 O'Donnell, p. 333.
18 Committee for Pro-Life Activities, National Conference of Catholic Bishops, Nutrition and Hydration: Moral and Pastoral Reflections, (Washington DC: United States Catholic Conference Inc. 1992), (Henceforth referred to as NCCB committee).
19 Pontifical Council for Pastoral Assistance to Health Care Workers, Charter for Health Care Workers, (Boston: St. Paul Books and Media, 1995), p. 105. The Italian original, Carta Degli Operatori Sanitari was "approved and quickly confirmed in its entirety" by the Congregation for the Doctrine of the Faith.
20 Catechism of the Catholic Church, (no. 2278: cf. The Gospel of Life, 65).
21 The Pope is here quoting from the NCCB report no. 6, p. 7. This language is also used in The Ethical and Religious Directives no. 58. The Holy Father's talk was distributed by the Catholic News Service, Monday, October 5, 1998. For a brief summary of the talk see the Brooklyn Tablet, October 10, 1998.
22 James Rachels, "Active and Passive Euthanasia," the New England Journal of Medicine, Vol. 292, no. 2 (Jan. 9, 1975), pp. 78-80, as reprinted in Tom L. Beauchamp and LeRoy Walters, ed. Contemporary Issues in Bioethics, (4th ed.) (Belmont, California: Wadsworth Publishing Company, 1994), p. 439.
23 Ethical and Religious Directives, p. 22. For the reference to the influence of the Congregation for the Doctrine of the Faith, see the Most Reverend Alfred C. Hughes, "A Catholic Vision of Health Care as Reflected in the Ethical and Religious Directives for Catholic Health Care Services," in Russell E. Smith, ed.. The Gospel of Life and the Vision of Health Care (Braintree, Massachusetts: The Pope John XXIII Medical-Moral Research and Education Center, 1996), p. 8
24 NCCB committee, no. 4, p. 3.
25 William E. May et al., "Feeding and Hydrating the Permanently Unconscious and Other Vulnerable Persons." Issues in Law and Medicine, Vol. 111, no. 3, Winter 1987, pp. 203-211. Reprinted in James J. Walter and Thomas A. Shannon, ed., Quality of Life: The New Medical Dilemma, (New York: Paulist Press, 1990), pp. 195-202.
26 NCCB committee, no. 4, p. 3.
27 May et al., p. 198.
28 The Gospel of Life, no. 57.
29 William E. May et al., p. 199.
30 May et al., p. 199.
31 May et al., p. 200.
32 NCCB committee, no. 4, p. 4.
33 Ethical and Religious Directives, no. 57.
34 William E. May et al., p. 200.
35 In re Conroy, 98, New Jersey 321, 486A. 2d-1209(1985).
36 Jonsen, Veatch, Walters, pp. 222-226.
37 Cruzan V. Director, Missouri Dept. of Health, 110 S. Ct. 2841 (1990). For commentaries, Raymond J. Devettere, Practical Decision Making, pp. 247-256, and Jonsen, Veatch and Walters, pp. 229-237, where the text of the decision is reprinted with annotations.
38 Thomas A. Shannon and James A. Walter, "The PVS patient and the foregoing/withdrawing of medical nutrition and hydration." Theological Studies, 49 (December 1988), pp. 623-647. This article contains an important bibliography for the period from 1972-1988 concerning ANH.
39 Ethical and Religious Directives, p. 22.
40 For a similar recommendation, see Edmund D. Pellegrino, M.D., "Secular Bioethics and Catholic Medical Ethics: moral Philosophy at the Margins," in The Bishop and the Future of Catholic Health Care: Challenges and Opportunities, ed., Daniel P. Maher (Boston: Pope John XXIII Center, 1997) 28-42.
Monsignor George P. Graham received a J.C.D. degree from the Catholic University of America and a Ph.D. degree from New York University. He served the Diocese of Rockville Centre in New York as Vice-Chancellor, Vice-Officialis and Officialis. He has been pastor of St. Bernard's Parish in Levittown since 1981. He is the author of William James and the Affirmation of God (New York: Peter Lang, 1992) and articles and book reviews in the Jurist, the Proceedings of the Canon Law Society of America, and Homiletic and Pastoral Review. © The Homiletic & Pastoral Review, 86 Riverside Dr., New York, N.Y. 10024, (212) 799-2600.
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