Hard to Understand?

by Thomas A. Szyszkiewicz

In a March 20 speech to an international gathering on the medical condition known as the “persistent vegetative state,” Pope John Paul II said that any person in that state is still fully human, and that withdrawing food and water—even if they are provided through a tube—constitutes “euthanasia.”

The Pope’s language was clear; his intent was unmistakable. “A man, even if seriously ill or disabled in the exercise of his highest functions, is and always will be a man, and he will never become a ‘vegetable’ or an ‘animal,’” the Pontiff said, indicating his disdain for the very term “persistent vegetative state.” Then he continued: “I should like particularly 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.” Such care, he continued, is “ordinary and proportionate, and as such morally obligatory.”

Although the Pope’s words were broad and sweeping, they applied directly to a very specific sort of case: the care of patients in persistent vegetative states. Yet as the National Catholic Bioethics Center pointed out [See Understanding the Pope's Position], the principle set forth by the Pope could be applied to many other cases.

“Death by starvation or dehydration,” the Pope added, “is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission.”

THE US REACTION

The clarity of the Pope’s message, however, is causing angst among many Catholic hospitals and some Catholic ethicists in the US, since many of the most prominent Catholic voices in the health-care field have been saying that it is acceptable to withhold food and water—in medical terms, nutrition and hydration—from people who are living in a persistent vegetative state. In some cases, they have asserted that withholding treatment can be morally justifiable even when the patient is conscious.

Bishop Elio Sgreccia is the vice president of the Pontifical Academy for Life, which sponsored the March seminar at which the Pope delivered his statement. Bishop Sgreccia, in an opening speech to the gathering, said essentially the same thing that the Pope would later say; he asserted that all “vegetative” patients have a right to be provided with nutrition and hydration. According to the National Catholic Reporter, Father Kevin O’Rourke, a Dominican ethicist at Loyola University’s Stritch School of Medicine, responded to that opening address by circulating a statement for others to sign, calling Bishop Sgreccia’s remarks “irresponsible” and inconsistent with “the many statements offered by medical societies, individual bishops, and conferences of bishops.”

For years, the Catholic Health Association—and certain Catholic ethicists, including Father O’Rourke—have been saying that if a vegetative patient requires medical assistance (such as a feeding tube) in order to receive food and water, then that approach is burdensome, and not morally obligatory. These ethicists have argued that providing nutrition and hydration through tubes is a form of medical treatment rather than ordinary care.

This approach has led the Catholic Health Association (CHA) and leading Catholic health-care institutions in the US to make repeated legal interventions in favor of withholding this “treatment.” For example:

• In a 2001 California case, three Catholic health organizations joined with a number of secular groups in filing an amicus brief with the California Supreme Court in support of withdrawing food and water from a man who, although severely brain damaged, was fully conscious. Robert Wendland was in a single-car accident because of drunkenness, went into a coma for 15 months and finally emerged from his coma with severe brain damage. One day, after his feeding tube fell out four times, his wife ordered that it be removed. The attending physician consulted the hospital’s ethics committee, which agreed to the move. However, when Wendland’s mother learned of the plan, she sued to preserve the feeding tube. She won her case in the lower court, but when an appeals court reversed part of that decision, the mother appealed to the Supreme Court. Wendland died before the Supreme Court issued its judgment, but the Court ruled in the mother’s favor.

• Steven Becker suffered from a cyst and excessive fluid on his brain, and was admitted to St. John’s Mercy Medical Center in St. Louis. He had emergency surgery, but did not recover full consciousness. Under pressure from the institution’s ethics committee, his wife agreed to have a feeding tube withdrawn. Becker’s mother disagreed, sued for custody, and won a restraining order to keep the feeding tube intact. Then-Archbishop Justin Rigali of St. Louis, in a sharp public disagreement with the hospital, told officials that they could not be justified in removing the feeding tube. In a truly bizarre twist to the story, Becker disappeared from the hospital in the middle of the night. His mother had obtained a continuance on the restraining order, but could not find Becker to serve it. One hour before the continuance could be served, he died in his home.

• The father of Alaska attorney Wayne Ross was admitted in August 1990 to Providence Alaska Medical Center, a Catholic facility in Anchorage, after suffering a stroke. The older man lapsed into a coma, and after two weeks a nurse told Ross the condition was irreversible. She added: “If you want, we could remove the food and water.” Ross, who prides himself on being straightforward in his speech, replied: “Are you nuts? Those are basic necessities.” He did not pursue the question. But later he reflected that when she raised the issue with him, the nurse “spoke as if it was just common procedure to offer” to end the patient’s life.

CHA ANSWERS THE POPE

After the Pope’s speech in March, the CHA offered a quiet response. The CHA offered “Resources for Understanding the Pope’s Allocution” on its web site, but the material was available only to the group’s members. (The organization’s “resources” on genomics, on the other hand, are available to all interested parties.) CWR was able to obtain the CHA response, and the closely-guarded material seems to indicate that the organization is asking some serious questions about its understanding of Catholic teaching on the subject. The attached sidebar shows a table contrasting the positions that the CHA took to be Church teaching prior to the Pope’s statement with the content of the Pope’s actual address. Some ethicists might question whether the positions put forward on the left column of the table—the CHA positions—represent an accurate understanding of universal Church teachings prior to the Pope’s March address. But it is difficult to deny the conflict between the views represented in the two separate columns. In a question-and-answer section of its response to the speech, the CHA grapples with that fact:

Q: Does the Pope’s recent allocution represent a shift in the Catholic Church’s approach to medically administered nutrition and hydration?

A: Insofar as the Pope refers to medically administered nutrition and hydration as a “natural means of preserving life” and, therefore, as ordinary means and morally obligatory, there does seem to be a change in the Church’s teaching on this issue. The implications of this change, however, are not entirely clear at this time.

The CHA communications director would not make a representative available to talk with this reporter. The group did issue a statement:

The Holy Father’s recent allocution affirms the Church and the Catholic health ministry’s abiding commitment to the inviolable dignity of human persons no matter their physical or medical condition. It reminds us of our responsibility never to abandon the sick and dying.

That being said, the guidance contained in his remarks has significant ethical, legal, clinical, and pastoral implications that must be carefully considered. This will require dialogue among sponsors, bishops, and providers, especially with regard to practical implications for those patients who are not in a persistent vegetative state.

Representatives from some of the largest Catholic health organizations in the US—Ascension, Catholic Healthcare West, and Catholic Health Initiatives—either did not return calls, or referred questions back to the CHA, or said that the question “requires further discussion.” Declining to speak for attribution, one spokesman followed up the latter observation by saying that the Pope’s statement “can’t be understood” on its own, and that until “further discussion” clarifies the issue, the Catholic health organizations will remain bound by the “Ethical and Religious Directives” approved by the US Conference of Catholic Bishops.

William Cox, executive director of the Alliance for Catholic Health Care, an association of all the Catholic hospitals in California, acknowledged the importance of the Pope’s address indirectly by saying that his group would “subject that statement to rigorous theological and ethical review.”

OVERREACTIONS

At least one observer seemed almost bemused by the fuss stirred up in American Catholic circles by the Pope’s remarks. Dr. Eugene Diamond, the editor of the Linacre Quarterly, the publication of the Catholic Medical Association, suggested that the Pope’s statement was forcing American Catholic officials to confront the moral admissibility of practices that they had been willing to defend—or at least tacitly accept. “It’s fascinating to see the overreaction of people who have been doing these things surreptitiously,” he said.

Actually, the feverish response to the Pope’s statement by the American Catholic health-care establishment seems to be a delayed reaction—delayed by about six years. In 1998, during an ad limina visit by the bishops of California, Nevada, and Hawaii, the Holy Father told the American bishops essentially the same thing that he would say in his March 2004 speech. Care must be taken, he said, to distinguish between “over-zealous treatment” and “taking away the ordinary means of preserving life, such as feeding, hydration, and normal medical care.” The Pope continued:

The statement of the United States bishops’ pro-life committee, “Nutrition and Hydration: Moral and Pastoral Considerations,” rightly emphasizes that the omission of nutrition and hydration intended 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. To blur this distinction is to introduce a source of countless injustices and much additional anguish, affecting both those already suffering from ill health or the deterioration which comes with age, and their loved ones.

In 1998, that papal address went nearly unnoticed. But Father O’Rourke, writing in the August 2001 issue of the Linacre Quarterly, set the tone for what is happening today, by downplaying the significance of the Holy Father’s remarks. The address, he wrote, “led some people to maintain that the Holy Father was proposing a clear teaching that AHN [artificial hydration and nutrition] could not be removed from PVS [permanent vegetative state] patients because it offered ‘normal care.’”

Father O’Rourke said this interpretation of the Pope’s position was “an overreaction” to the address. “Health care,” he wrote, “seeks to enable people to strive for the purpose of life, not merely to function at the biological level.” But for people living in a persistent vegetative state, no care or treatment is likely to improve their ability to “strive for the purpose of life.” In such cases—where medical treatment is unlikely to provide any tangible improvement—Father O’Rourke said that Catholic teaching had traditionally emphasized two different opinions: 1) that removing food and fluid is euthanasia and, therefore, always wrong; and 2) that there should be a presumption in favor of providing such care, but that it can be removed if it is excessively burdensome or offers no hope for sustaining life. While these two opinions could trace their origin back to the theologians of 16th-century Salamanca, he said that 20th-century ethicists had developed a third opinion: that food and water, delivered through a tube to a patient in a vegetative state, offers no hope of benefit to the patient, his family, or his community.

Returning now to the Pope’s address, Father O’Rourke said that “it would be rash to maintain that he was correcting bishops who have affirmed the third opinion or approved the actions of their parishioners who acted in accord with the third opinion.” While the Pope’s 1998 talk to the visiting American bishops seemed to indicate a preference for providing food and water, Father O’Rourke insisted that “it cannot be maintained that the third opinion is rejected.” (Lest there be any lingering doubts, he helpfully added that the Pope’s remarks were “not a definitive statement of doctrine.”)

Father O’Rourke observed: “The Pope maintains that AHN should be provided ‘to all patients who need them.’ However, he offers no clarification as to how to assess necessity in the concrete situation.” He observed that all ethicists would agree on this point: “that AHN should be provided when ethically necessary.” But that statement begs the question: When is it ethically necessary?

Father Edward Richard, a LaSalette missionary priest and academic dean of the Kendrick-Glennon seminary in St. Louis, took exception to Father O’Rourke’s characterization of Church teaching. In treating the provision of nutrition and hydration as a form of medical treatment, he said, he overlooked the fact that food and water constitute standard care for a patient—care that should be provided out of a fundamental respect for human dignity, regardless of the patient’s medical prognosis. “They treated this as if it was intended to bring about some cure,” he said. This distinction is critical, he continued, because in the Catholic moral tradition, a moral act must be judged by the end toward which it is directed.

Another problem with the “third opinion” lies in the underlying diagnosis that a patient is in a “persistent vegetative state.” Once that diagnosis has been made, and doctors assert that the patient has no realistic hope of recovery, medical treatment is generally suspended. Father Richard comments that in many cases the diagnosis of PVS “has been a self-fulfilling prophecy because they didn’t do anything for them.” Yet in numerous cases, a patient who was diagnosed as being in a persistent vegetative state has eventually enjoyed a full recovery. In light of the abuses that are possible (and, according to some witnesses, commonplace) once a patient is declared to be in a PVS, is it prudent to assume that continuing nutrition and hydration cannot possibly help the patient?

Another question that probably requires further study, Father Richard observes, is the different means of providing food and water through a feeding tube. But at a time when doctors can readily install tubes in a matter of minutes, he observes, “you can’t classify this as burdensome treatment.”

NOT WHAT THEY WANTED

After the Pope’s speech on March 20, American newspapers from St. Petersburg, Florida, to Seattle, Washington, carried stories about how the papal statement would affect Catholic health care in the US. In a representative story, USA Today reported:

Pope John Paul II has stunned Catholic health care providers, ethicists, and theologians by announcing emphatically that it is “morally obligatory” to continue artificial feeding and hydration for people in a persistent vegetative state, even if they remain so for years.

His comments could require revision in directives on end-of-life care at 1 in 10 US hospitals. And they may prompt confusion over the validity of advance directives people have drawn up that say they do not want “extraordinary” treatments to prolong their life under specified circumstances.”

Some Catholic hospitals even rushed to assure potential patients that they would still honor the terms of their living wills.

One Catholic hospital system that did not respond nervously to the Pope’s speech was the Sisters of St. Francis Health Services in Indiana. For that Catholic health-care system, the Pope’s statement merely confirmed a longstanding policy. Gene Diamond, who supervises three of the system’s hospitals, explained: “The Sisters of St. Francis have long since developed a nutrition and hydration position where we only withdraw when death is imminent and when it would compromise underlying conditions,” he said.

Gene Diamond (the son of Dr. Eugene Diamond, who was quoted above) said that potential patients of the Sisters of St. Francis Health Services were also unmoved by the Pope’s statement, since his group had done “a pretty good job of defining our position.” In sharp contrast, other large Catholic hospital chains, and the CHA, were clearly unsettled by the papal directive. “The fact that they need to study it and dialogue on it tells you that’s not at all what they wanted to hear,” Diamond said.

COMMON PRACTICES AND COMMON BELIEFS

In practice, it is not clear how much the Pope’s statement would affect Catholic hospitals in the US, since most of the patients who have been diagnosed with PVS are confined in long-term-care facilities such as nursing homes. “We have 35,000 acute-care admissions a year,” Gene Diamond reported, “and the number of patients treated for PVS is very small.”

Nevertheless, Gene Diamond’s father observed that the slant on news coverage on the Pope’s address revealed the widespread belief that most Catholic hospitals in America do not follow the same policies that the Sisters of St. Francis Health Services proudly publicize. Said Dr. Eugene Diamond, the media response to the Pope’s remarks betray “the assumption … that the CHA and Father O’Rourke have dictated what goes on in Catholic hospitals.”

In fact, Dr. Diamond contended, the approach taken by the CHA and Father O’Rourke represents only a minority opinion among Catholic ethicists. “The redefinition of life is unique to Father O’Rourke,” he argues. And regarding the care provided for people diagnosed with PVS, Dr. Diamond points out that it is misleading to suggest that difficult and painful decisions about end-of-life treatment are involved, since “we’re talking about people who are not dying.”

The senior Diamond was actually a participant at the March conference in Rome, and delivered his own address, in which he virtually echoed the position taken by both the Pope and Bishop Sgreccia. In fact, of the 400 participants who had come from all around the world to attend that meeting on treatment of PVS patients, he estimated that 300 were already supportive of the teaching the Pope advanced.

For precisely that reason, Rita Marker welcomed the Pope’s statement as a clear articulation of the Church’s position. “The teaching has always been there,” she said.

Marker, the director of the International Task Force on Euthanasia and Assisted Suicide in Steubenville, Ohio, disputes the CHA contention that the use of a feeding tube constitutes extraordinary care; she reports that she found a statement in an 1896 Kentucky medical journal saying that feeding by a tube was commonplace at that time, more than a century ago. And while USA Today fretted about Catholic patients who do not want to receive extraordinary treatment, Marker pointed out that anyone who uses that term, “extraordinary treatment,” in a living will should revise the document in any case. “There is no legal definition of what that means,” she said.

However, Marker had another reason to welcome the Pope’s statement, because in her work with end-of-life cases she has frequently encountered situations in which the families of PVS patients were subjected to “a tremendous amount of browbeating” by hospital officials who recommended removing feeding tubes. Worse, she reported, the pressure on families “is often done by ethics committees and chaplains.”

In his March address, Pope John Paul referred to such manipulative tactics, urging Catholic health-care officials to “stand against pressures to withdraw hydration and nutrition as a way to put an end to the lives of these patients.” He also urged new effort “to support those families who have had one of their loved ones struck down by this terrible clinical condition. They cannot be left alone with their heavy human, psychological, and financial burden.”

While the CHA still plans to study the implications of the Pope’s remarks, one moral theologian, Dr. John Grabowski of Catholic University of America, asserts the Pope made it “unambiguously clear” that providing food and water is ordinary care, even if they are delivered through a tube. “The comatose person is not dying,” he observes.” You don’t lose your personal dignity or worth because you’re brain-damaged.”

Or as one 14-year-old girl pointed out, “Even vegetables need food and water.”

UNDERSTANDING THE POPE’S POSITION

The following statement was released by the National Catholic Bioethics Center (NCBC) in response to questions about the Pope’s March 20 address.

The ethicists of the NCBC have begun a careful examination of Pope John Paul II’s recent allocution on life sustaining measures and patients in a comatose state. It is a welcome clarification of Catholic thinking on one of the most vexing and controversial issues in health care. The Pope’s words correct a serious misunderstanding about the circumstances in which nutrition and hydration may be removed from a patient in a coma.

This statement has implications not only for comatose patients but for all patients who receive or may receive food and water. Many advance directives, which Catholics formerly signed in good faith, and which require the removal of food and water in cases of coma, may have to be reconsidered.

The words of the Holy Father should settle three related debates among Catholic moralists:

1. When dealing with comatose patients, some had contended that the presumption should be not to provide nutrition and hydration artificially [ANH] whereas others insisted that the presumption must be to provide nutrition and hydration, even when delivered artificially. The Pope clearly decides in favor of the latter.

2. The second point of clarification was whether artificial nutrition and hydration is care or treatment. The Pope is clear: he considers it care. Its purpose is nourishment. Removal of food and water is permissible in the case of a patient in the vegetative state only when their provision can no longer attain nourishment.

3. Points one and two show that in general the provision of nutrition and hydration to the patient in the vegetative state is proportionate and morally obligatory, but that in a particular case nutrition and hydration may be extraordinary and disproportionate, and, therefore, morally optional.

The Pope has also rejected the use of the “quality of life” standard as the sole principle for medical decision-making on behalf of patients in the vegetative state. He has reaffirmed the complete humanity and dignity of these persons.

Since the Pope has a global audience, we may assume that he is also addressing the situation in the Netherlands where euthanasia is now legal. The withdrawal of nutrition and hydration with the intent of killing the patient is euthanasia. The same holds true obviously for an intentional overdose of pain medication.

There is no departure from tradition in the Holy Father’s remarks; hence, the customary moral categories used in Catholic health care still hold. The Pope has articulated a general principle for providing nutrition and hydration to patients, including those in a comatose state. The allocution should be interpreted to allow for prudential case-specific judgments.

While the Pope has settled some debates among Catholics, there are issues he did not address such as the ethical significance of the modes of delivery of ANH, types of coma, the significance of the imminence of death, and who should bear the costs of the continued provision of ANH. These issues will continue to be debated by ethicists and theologians applying the Pope’s recent articulation of Catholic moral principles.

While this important discussion goes on, the Holy Father in his allocution of March 20, 2004, has reminded all who are involved in the healing professions that health care must be inclusive rather than exclusive. In this regard, note the lone scriptural citation in the allocution: “Amen, I say to you, whatever you did for one of these least brothers of mine, you did for me.” (Mt 25:40)

Thomas A. Szyszkiewicz is a free-lance writer based in Minnesota.

© Ignatius Press

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