Death Without Dignity: Starvation and Dehydration

by Robert C. Cetrulo

An article in the January 2006 edition of the St. Anthony Messenger, "Feeding Tubes: Choice or Obligation"¹ calls for a deeper examination of the issues involved in the removal of the normative means of nutrition and hydration (food and water) from a patient unable to care for himself. The author, a Catholic and a physician, misses three crucial points in his analysis: 1. The brutality of death by starvation and dehydration 2. The nature of a "medical act" in Catholic moral theology. 3. The obedience owed by a Catholic to the ordinary Magisterium of the Church in matters of faith and morals. A more exacting analysis of each of these points will illustrate the dangerous misunderstandings currently at work in the analyses offered by many Catholic theologians and health care providers related to the administration of feeding tubes. Failing to grasp the moral import of this issue has already led to the starvation and dehydration of defenseless persons, amounting to medically imposed capital punishment for the innocent.

The brutality of this capital punishment of the innocent, imposed via starvation and dehydration — which is what occurs when a feeding tube is removed — cannot be ignored in the moral analysis of this situation. If the Constitution of the United States disallows capital punishment that is both "cruel and unusual how much more so should Catholic health care providers and moral theologians avoid imposing a death sentence on an innocent, using a means of execution far more cruel and unusual than any currently in use for the guilty of our land? The opinion of the Massachusetts Supreme Court — Brophy v. New England Hospital — describes the situation well:

Various effects from lack of hydration and nutrition, lead ultimately to death — mouth would dry out and become caked or coated with thick material . . . lips would become parched and cracked . . . tongue would swell and might crack . . . eyes would recede back into their orbits and cheeks would become hollow . . . lining of the nose might crack and cause the nose to bleed . . . skin would hang loose on his body and become dry and scaly . . . urine would become highly concentrated; leading to burning of the bladder . . . lining of his stomach would dry out, causing convulsions . . . respiratory tract would dry out into thick secretions that would result in plugging his lungs . . . at some point within 5 days 103 weeks his major organs, including lungs, heart, and brain would give out and he would die . . . extremely painful and uncomfortable . . . cruel and violent.

In the recent case of Terry Schiavo, we find ample testimony to the truth of this description. Fr. Frank Pavone, the Director of Priests for Life, was present for most of the two-week period of her death by starvation and dehydration. He stated: "Terri's death was not at all peaceful and beautiful. It was quite horrifying. She is dehydrating to death and looked it. Her face had an expression of dread and sorrow." The all-to-frequent invocation of the pro-death slogan, "right to die," is a not-so-subtle effort to mask the hard fact that Terri, as well as the vast majority of patients on feeding tubes, was not and are not dying. It is an incontrovertible fact that if their feeding tubes were removed, they would be affirmatively killed by starvation and dehydration, just as Terri was.

Unbroken chain of Catholic teaching

Those Catholic moral analysts and health-care providers who assert that the main issue in the Schiavo case was not the morality of the feeding tube itself, but the matter of who should decide, are guilty of ignorance in the least or malicious deception at the worst. The debate is not about choice, it is about the life and death of a human person who lived with the presumption that her loved ones would protect her from murder. We see a similar attempt to distract in the abortion debate. The fundamental fact is that abortion kills an innocent unborn child. This fact is elided by the "bait and switch" tactic that attempts to shift the focus from the reality of killing an innocent person to a question of "choice" on the part of the pregnant women. From both the perspective of sound law and moral analysis, the starting point here is not one of "choice," but of the obligation to protect innocent and defenseless life from aggression and murder.

Inherent to every human person is the dignity afforded to that person because he is created in the image and likeness of God. This fundamental fact is at the foundation of moral analysis in the Catholic moral tradition. So, when one is in the situation of making important moral deliberations as they relate to the life and death of a person, it is never appropriate to start with the subjective and ultimately unverifiable claim of "what the person wanted," especially if what they would have wanted is not in keeping with the dignity inherent to the human person. Simply because a person in life had the power to speak against, act against, and even sin against their human dignity, does not give caregivers, most especially Catholic ones, the license to do the same.

Catholic moral analysis begins with an examination of acts, not of intentions. When deliberations are being made as to how to care for a patient in a "vegetative state," it must first be said that a human person is never really in a "vegetative state" in the sense that due to some infirmity they become less than a human person. In the recent case of Terry Schiavo, important facts as to her actual condition were ignored. She was not actively dying; she had no terminal condition, was on no artificial life support system, and depended for survival only upon food and water, as do each of us. That she received her food and water through a feeding tube, which is neither painful nor difficult to manage, does not change the fact that she was the object of normative human care, not extraordinary medical care. "Death by starvation and dehydration is . . . always 'serious violation of the law of God.'"² (Emphasis by Pope John Paul)

In the Catholic moral tradition, extraordinary means of preserving and maintaining human life are not required. Such extraordinary means include artificial life support for prolonged periods of time where the hope of recovery is judged unlikely, experimental treatments, and other expensive treatments that are judged unlikely to succeed in overcoming the pathology. The fact is food and water administered through a feeding tube is not a medical act, but an act of human compassion that is easily accomplished. His Holiness, Pope John Paul II pointed this out in his 2004 address to an international congress of health care workers:

I should like to particularly 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. Its use, furthermore, should be considered in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until ills seen to have attained its proper finality, which in the present can consist in providing nourishment to the patient and alleviation of his suffering.³

This unambiguous and universal moral mandate taught by the Pope, that the furnishing of food and water, even artificially, to every human being not in the imminent dying process is ordinary care, is made clear elsewhere by the citation of Pope John Paul II, in his paper, Charter for Healthcare Workers:

Here he will apply the principle already stated of 'appropriate medical treatment,' which can be specified thus: 'When inevitable death is Imminent, despite the means used, it is lawful in conscience to decide to refuse treatment that would only secure a precarious and painful prolongation of life, but without interrupting the normal treatment due to the patient in similar cases (author's emphasis). Hence the doctor need have no concern; it is not as if he had failed to assist the person in danger.

The administration of food 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 real and properly so-called euthanasia.⁴

Much was made of the Pope's 2004 statement as if it were somehow a new teaching, but in fact, the Holy Father is only offering a very traditional analysis of a now routine situation that arises in healthcare almost everyday. The preservation of life via the administration of a feeding tube, which delivers food and water, does not rise to the level of being either a medical act or an extraordinary means to preserve life. In most instances, the feeding tube is no more difficult to administer than an IV and with proper supervision. People in reduced physical states can and do live quite comfortably with them. Terry Schiavo herself is witness to this, as she lived for a number of years on a feeding tube, receiving the loving care of her family and friends on a daily basis. She died only when her husband decided to have her tube removed.

The Pope's reiteration of the traditional and correct moral analysis of the use of feeding tubes is not a function of some extraordinary pronouncement on the part of the teaching authority of the Papal Magisterium. It is a function of his and the Church's Ordinary Magisterium "to confirm the brethren" in the truth. Throughout the debate over whether Terry Schiavo's feeding tube should be removed, a number of "Catholic" theologians, such as Frs. Kevin O'Rourke, O.P., and Richard McBrien pretended as if the Pope had said something new and then questioned his authority to make such an extraordinary moral pronouncement.

What the Pope asserted was nothing more than the truth contained in the Church's deposit of faith that is handed on to us through the Ordinary Magisterium of the Church. The Ordinary Magisterium of the Church is simply the teaching authority of the Church as exercised in ordinary day-to-day circumstances. What is extraordinary about the Pope's statement is not that he offered it, but that so many prelates, priests, healthcare providers and moral theologians rejected the truth it contained and actively supported the active killing of a woman by the removal of her feeding tube, which provided her with life-sustaining food and water. Clearly, the Pope's public and unequivocal witness to the Fifth Commandment of the Decalogue "thou shall not kill" makes unambiguous the moral mandate of the Gospel — even if the method of the killing is to remove one's mode of receiving food and water.

All Catholics are obliged to give their full assent to all that is proposed by the Ordinary Magisterium of the Church, not just those things proposed in extraordinary ways, such as by a solemn definition of an ecumenical council or by a "ex cathedra" proclamation issued by the Supreme Pontiff.

Two canons, from the Universal Code of Canon Law are instructive on this point:

Those things are to be believed by the divine and Catholic faith which are contained in the word of God as it has been written or handed down by tradition, that is, in the single deposit of faith entrusted to the Church, and which at the same time proposed as divinely revealed either by the solemn Magisterium of the Church, or by its ordinary and universal Magisterium which in fact is manifested by the common adherence of Christ's faithful under the guidance of the sacred Magisterium. All are therefore bound to avoid any contrary doctrines (Canon 748, para. 1).

Furthermore each and everything set forth definitively by the Magisterium of the Church regarding teaching on faith and morals must be firmly accepted and held; namely, those things required for the holy keeping and faithful exposition of the deposit of faith; therefore, anyone who rejects propositions which are to be held definitively sets himself against the teaching of the Catholic Church. (750, para. 1).

The fact is, as Fr. Basil Cole, O.P., asserts in his article "Why So Long to Make a Decision?"⁵ "with this significant document of the Holy Father has definitively spoken . . . Many ethical concerns are laid to rest and those theologians who had a different view need to come on board by admitting their erroneous opinions and continue to write with Mother Church, not against."

The crux of the matter for the faithful Catholic is, as the eminent philosopher Ralph McInerny has recently noted on the Pontifications Blog:

The only permissible response of a Catholic to the Church's teaching is to accept it. Not to accept it is to say that you can be a good Catholic while rejecting Christ's Vicar on earth and the Magisterium that was divinely established in order that the deposit of faith might be transmitted from generation to generation in all its purity. What kind of Catholic rejects the solemn teaching of the Christ and His Church? It is one thing to fall short of Catholic teaching in our lives, to sin; and is quite another to reject the measure of action that is proposed by the Church. Too many Catholics have set themselves up as rivals to the Magisterium. The situation is not altered because they do so by taking the word of dissenting theologians that it is all right to do this or that.

The pattern is clear: What began as a quarrel about sexual morality (rejection of Humanae Vitae and Roe v. Wade) quickly escalated into a fundamental dispute as to what the Church is and where authority resides when it is a matter of what the Church teaches and what Catholics must believe . . . There is simply no justification for refusal to accept the clear teaching of the Pope (and the entirety of the moral tradition) on matters of faith and morals. There is no excuse for theologians telling the faithful to ignore magisterial teachings with which those theologians have difficulties. If the matter of misleading the faithful and deforming consciences were not so serious, the situation would be rendered comical by the fact that the reasons — theological and philosophical — that dissenting theologians offer are so often risibly weak and manifestly defective.

Since there has been a noticeable lack of retractions by the numerous theologians who sided with the pro-death camp, it is clear that what is needed is the prompt disciplining of dissident theologians by the Holy See, local bishops and other competent religious superiors. The pro-death theologians who persist in not only deceiving the faithful, but in providing theological cover for the murder of innocents deserve, in justice, to be held to account for their misdeeds. The fact that such persons hold positions of authority and prestige in Catholic institutions is a scandal of immense proportion. In a very real sense, no greater scandal imaginable could exist.

Slippery slope

Ideas have consequences and in matters of life and death, these consequences are frequently deadly. We are seeing the total degeneration of the ethic of the inviolable sanctity of every human life, inaugurated by the abortion decision Roe v. Wade. This ethic once formed and informed the moral foundation of all legal, medical, and moral decisions as they related to human life. Roe v. Wade, that fateful 1973 Supreme Court decision, substituted the "meaningful life" ethic for the inviolable sanctity of life ethic characteristic of the whole Judeo-Christian moral and legal tradition. It is horrific enough that this ethic has affected jurisprudence in our land, but to see the ethic given theological justification by representatives of the Church is almost too much to bear. The enshrinement of this "meaningful life ethic" in both jurisprudence and now theology has brought us to the present situation — the state-sanctioned killing, by starvation and dehydration, of an innocent woman who expected the state and representatives of the Gospel to protect her from harm.

This "meaningful life" ethic has caused a blurring between "healing" the object of a true medical act, and "killing," which is never sanctioned either by sound medicine or moral theology. The teaching of history is instructive on this point.

Recent experiences in Holland demonstrate the moral descent from tolerance of the practice of physician-assisted suicide limited to physically suffering, terminally ill and competent patients, through the judicial and medical approval of the non-consensual termination of patients' lives: ". . . from the assisted suicide to active euthanasia, from terminally ill to chronically ill, from voluntary to non-voluntary, and from physical illness to mental suffering. The gradual replacement, in both theory, moral deliberation, and legal procedure, of the absolute sanctity of life ethic with the relativistic, subjective "meaningful life" ethic is at the root of this degeneration, to catastrophic effect.

What is needed?

Dr. Leo Alexander, a psychiatric consultant at the Nazi war crimes trials of physicians at Nuremberg in the mid 1940s described the same moral descent:

'Whatever proportions these [German war] crimes finally assumed, it became evident to all who investigated them that they had started from small beginnings. The beginnings at first were merely a subtle shift in emphasis in the basic attitude of physicians. It started with the acceptance of the attitude, basic in the euthanasia movement, that there is such a life not worthy to be lived. This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those unproductive, the ideologically unwanted, the racially 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 rehabilitable sick.

In our own nation, we have seen the initial legislative efforts of "death with dignity" limited to the patient's free choice to withdraw truly medical methods of the preservation of life, such as ventilators, to legislation which permitted the patient to choose to withdraw food and water. This has progressed even further to legislative and judicial decisions allowing others to make that decision for the patient when the patient has not, and in many instances, cannot make that decision for himself.

The dying process can be a crucial time to make peace with God, oneself, and loved ones. To cut short this crucial time by euthanasia or assisted suicide, and to have ministers of the Gospel provide theological cover for such a thing, is the most awful betrayal imaginable to a dying person. To deny someone that time period to say or have said by the ministers of the Church on their behalf and the vicarious prayers of loved ones: "You are forgiven — forgive me — thank you — I love you — goodbye" is a most shocking denial of the proper, essential supernatural end of the dying process.

The death process is the time of preparation for the end with solemn, prayerful, and sacramental dignity. The clear teaching and pastoral practice of the Church is to attend to that preparation, by offering and attending the dying person with a personal encounter with Christ in the sacraments of Reconciliation, Anointing of the Sick, and Viaticum — if they are physically able to receive it. The dying person, whether he is a great saint or the most public of sinners, is surrounded by mercy and grace because the dying person is preparing to meet and give an account to his God. In these last stages, the way in which we prepare and let others prepare is an eloquent testimony to the inherent dignity of human life, no matter how diminished the dying person's faculties may be.

In the meantime, everyone should execute pro-life, end of life documents, such as the living will and medical power-of-attorney, expressing these principles of sound morality and medical practice, in order to protect themselves from the horrible death of starvation and dehydration.

I wish to acknowledge the substantial and valuable contributions to this article made by Theodore H. Miller, M.D., Ph.D., chairman of the Medical Ethics Committee at St. Luke Hospitals and by the Reverend Phillip W. De Vous, M.Div., the parish priest of Divine Mercy and St. Bernard Parishes, who also serves as an adjunct scholar of public policy at the Acton Institute in Grand Rapids, Mich.

End Notes

1. Sulmasy, Daniel. "Feeding Tubes: Choice or Obligation," St. Anthony Messenger, January 2006.

2. Address of John Paul II to the International Congress on "Life Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas" March 20, 2004.

3. Ibid.

4. John Paul II, Charter for Healthcare Workers, Note 120.

5. Basil Cole, O.P. "Why So Long to Make a Decision?" in Homiletic & Pastoral Review, Dec. 2004.

6. Issues in law and Medicine (Winter 1998, Vol. 14 No. 3).

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Robert C. Cetrulo, J.D., has 47 years of legal experience, including 15 years as a U.S. Magistrate Judge. He is the past president of the local bar association, past president of the state bar association, as well as a teacher of constitutional law. He has lectured on many topics and is the author of numerous articles and the book, That Reminds Me of a Story . . . Reflections of a Pro-Life Warrior, available through Northern Kentucky Right to Life Educational Foundation, 1822 Madison Ave., P.O. Box 1202, Covington, KY 41012. This is Mr. Cetrulo's fourth article in HPR.

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