Caring for Persons in the Persistent Vegetative State
Introduction
My purpose here is to offer reflections on the care to be given to persons said to be in the "persistent vegetative state," and specifically to address the question whether or not it is obligatory to provide persons said to be in this condition with nutrition and hydration (hereafter I will simply use the term "food" to cover both nutrition and hydration) by the use of artificial means.
Meaning of "Persistent Vegetative State"
It is first of all important to have a correct understanding of what is meant by a "persistent vegetative state."1 From the perspective of medicine, individuals in this condition are not comatose. A true coma, which is never permanent, is a state of "unarousable unresponsiveness" which may last as long as six months but will eventually resolve itself into another state.2 The person may emerge into consciousness (of varying degrees) or sink into the "persistent vegetative state," and it may take a long time, even months, to make a correct diagnosis of the patient's true condition.
The "persistent vegetative state" is a form of deep unconsciousness. The upper part of the brain, the cerebrum, gives evidence of impaired or failed operation. Since it is this portion of the brain, in its cortex or outer layer, which is neurologically involved in specifically human activities such as understanding, willing, and communicating, persons in this condition are not capable of engaging in specifically human activities. But the brain stem, which controls involuntary functions such as breathing, blinking, cycles of waking and sleeping, etc., is still functioning. As a result, patients in this condition may open their eyes and sometimes follow movements with them or respond to loud or sudden noises (although such responses will not be long sustained nor are they apparently purposeful).3 It is quite unlikely that persons in this state will ever recover consciousness. However, their condition has stabilized and they are not in any immediate danger of death so long as they are given appropriate "food," which can be provided to them "artificially" by means of tubes.4
Since persons diagnosed as being in the "persisent vegetative state" are by no means imminently in danger of death and since their lives can be prolonged, perhaps for many years, if they are fed and nourished, the principal moral question raised in caring for them is whether or not it is morally obligatory to provide them with "food" by the artificial means described in footnote no. 4.
Different Moral Responses
The universal Magisterium of the Church has not specifically addressed this issue. However, several moral theologians and, in the United States, bishops' conferences, individual bishops, and a committee of the National Conference of Catholic bishops have written articles or issued statements on this matter, with some concluding that it is normally required to provide such persons with food by artificial means (although in specific cases it might be morally permissible to withhold or withdraw artificially provided food) and others holding that it is morally legitimate to withhold or withdraw the provision of food by these means. It will be useful here to summarize, in a note, representative positions taken by U.S. bishops.5 Since even bishops offer conflicting advice on the morality of providing food artificially to persons in the persistent vegetative state, it is evident that the issue is a most difficult one to address properly.
Ten years ago I collaborated in writing an article on this issue. My collaborators and I concluded that, ordinarily, it is morally obligatory to provide food artificially to permanently unconscious persons.6 Here, in order to defend, clarify, and amplify the position developed in that essay I will first (1) articulate criteria justifying the decision to withhold or withdraw treatments from human persons. In setting forth these criteria I will also criticize criteria proposed by influential Catholic theologians because of their inadequacies. I will then (2) apply these criteria to the artificial feeding of patients in the "persistent vegetative state," developing and clarifying considerations set forth in the 1987 article. I will conclude (3) by considering conditions that could justify putting limits to the care morally due to persons in this state.
1. Criteria for withholding/withdrawing treatment
My purpose here is to articulate the criteria necessary for distinguishing between treatments which the Catholic tradition has called "ordinary" or, more recently, "proportionate," and those termed "extraordinary" or, more recently, "disproportionate."
Relevant Church teaching
In elaborating these criteria several document of the Church's Magisterium are quite relevant. Here I will call attention to two such documents. The first is an important address of Pope Pius XII in 1957, when he spoke to a congress of anesthesiologists. In the course of his remarks, Pius had this to say:
But normally one is held to use only ordinary means [to prolong life]--according to the circumstances of persons, places, times, and culture--that is to say, means that do not involve any grave burdens for oneself or another. A stricter obligation would be too burdensome for most men and would render the attainment of the higher, more important good too difficult. Life, health, all temporal activities are in fact subordinated to spiritual ends. On the other hand, one is not forbidden to take more than the strictly necessary steps to preserve life and health so long as he does not fail in some more important duty.7
Here Pius indicates that "ordinary" medical treatment is that kind of treatment which offers some reasonable hope of benefiting the subject without imposing unacceptable burdens upon him or others, whereas "extraordinary" treatment is the kind that imposes unacceptable burdens on the subject and/or others. The Pope himself did not address the specific criteria for distinguishing between treatments which are ordinary or proportionate and those which are extraordinary or disproportionate. Rather, he outlined a general approach that seems clear enough, but one which obviously needs interpretation and requires further specification.
A central problem in interpreting this statement of Pope Pius XII, as will be seen, has to do with the proper way of understanding what he meant when he said that life, i.e., bodily, physical life, is subordinated to "spiritual ends." I will return to this problem below, in commenting on views which I deem unacceptable and indeed dangerous.
A major document of the Magisterium relevant to our question is the Declaration on Euthanasia issued by the Congregation for the Doctrine of the Faith in 1980. While unequivocally condemning as absolutely immoral suicide and all forms of euthanasia, whether by acts of commission or by acts of omission, this document reaffirmed traditional Catholic teaching that one is not obliged to use all possible means to preserve and prolong human life. It referred to the traditional distinction between "ordinary" and "extraordinary" means of preserving life, noting that the imprecision of these terms is the cause of some ambiguity and that, therefore, some more recent writers had suggested that the term "proportionate" be used to designate means that are morally obligatory and that the term "disproportionate" be used to designate means which are not morally obligatory. It stated that no matter what terms are used to signify the distinction, it would nonetheless be possible to make a correct judgment
by studying the type of treatment to be used, its degrees of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources.8
Moreover, the same document maintained that "one cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results which can be expected, or a desire not to impose excessive expense on the family or community."9 In addition, this document continues, "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 which would only secure a precarious and burdensome prolongation of life, so long as the normal care due to a sick person in similar cases is not interrupted."10
The precise significance of these statements will be explored in depth later on. For the present I can simply say that this document clearly indicates that medical treatments judged, on objective grounds, to impose grave burdens either upon the subject being treated or his family or, indeed, the human community of which the subject is a member, are not morally required and hence can be legitimately withheld or withdrawn. In assessing these burdens, moreover, it is necessary to take into account the resources, physical and moral, of the subject. It is likewise legitimate to take into account the burdens, including financial burdens, which the treatment will impose upon others.
Erroneous criteria for judging means "extraordinary" or "disproportionate"
In the previous section I called attention to Pope Pius XII's address to anesthesiologists not only because it is an important magisterial document relevant to identifying criteria necessary for distinguishing between "ordinary" (=morally obligatory) and "extraordinary" (=morally elective) means of treatment but also because one interpretation of a singularly important passage from this document has been used by several theologians to justify withholding or withdrawing artificially provided food from persons in the "persistent vegetative state."
This interpretation, or in my judgment, misinterpretation of the teaching of Pius XII has been advanced in particular by Kevin O'Rourke, OP, in several very influential essays dealing with the care of permanently unconscious persons.11 A view very similar to O'Rourke's, although different in some respects, has been set forth by James Walter and Thomas V. Shannon.12 Here I will simply recount O'Rourke's position insofar as on the matters to be taken up Walter and Shannon are in agreement with him.
O'Rourke's position is in large measure rooted in his understanding of the passage from Pope Pius XII's address that we have already examined, in particular, that portion of his talk in which Pius said that excessively burdensome treatments would "render the attainment of the higher, more important good too difficult" and that "life, health, all temporal activities are in fact subordinated to spiritual ends." O'Rourke claims that the Pope's emphasis on the spiritual goal of life
specifies more clearly the terms "ordinary" and "extraordinary." A more adequate and complete explanation of "ordinary" means to prolong life would be: those means which are obligatory because they enable a person to strive for the spiritual purpose of life. "Extraordinary" means would seem to be those means which are optional because they are ineffective or a grave burden in helping a person strive for the spiritual purpose of life.13
O'Rourke correctly interprets the teaching of Pius XII when he says that a means is extraordinary if it imposes a grave burden on a person and prevents him from pursuing the spiritual goal of life. But he errs greatly, I hold, when he claims that a means is extraordinary when it is "ineffective...in helping a person strive for the spiritual purpose of life" and that a means is ordinary precisely because it enables a person to strive for the spiritual purpose of life. Many people, including some seriously handicapped children and mentally impaired adults, are incapable of pursuing the spiritual goal of life. They cannot do so because in order to do so a person must be able to make judgments and free choices. But these unfortunate human beings are still persons; their lives are still good, and it is good for them to be alive. If they should fall sick or be otherwise in danger of death, they surely have a right to "ordinary" care, and others have a serious moral responsibility to protect and preserve their lives unless the efforts to do so are futile or excessively burdensome. Thus, for example, if an elderly person suffering from a malady that renders him incompetent and incapable of engaging in human acts should suffer a cut artery and be in danger of dying because of loss of blood, it would surely be morally obligatory to stop the bleeding by appropriate means. Such means are surely "ordinary" or "proportionate." Yet, on O'Rourke's analysis, they would be "extraordinary" inasmuch as they would in no way be effective in helping this person to pursue the spiritual purpose of life.
ENDNOTES
1It is in my opinion unfortunate that the expression "persistent vegetative state" has been employed to describe the condition of human persons. Use of this expression leads some to think that individuals in this state are no longer truly human persons but rather "vegetables," but this, of course, is not true at all. Such individuals are still human persons whose lives are inviolable.
2See Council on Scientific Affairs and Council of Ethical and Judicial Affairs, Persistent Vegetative State and the Decision to Withdraw or Withhold Life Support, in "Journal of the American Medical Association" 263 (January 19, 1990) 427: "Abrupt loss of consciousness usually consists of an acute sleep-like state of unarousability called coma that may be followed either by varying degrees of cognitive and physical recovery or by severe, chronic neurological impairment. The stage of coma itself, however, is invariably temporary and in progressive disease is often absent altogether."
3See Ronald Cranford, The Persistent Vegetative State: The Medical Reality (Getting the Facts Straight), in "Hastings Center Report" 18 (February-March, 1988) 27-32.
4In their Pastoral Letter of January 14, 1992, Nutrition and Hydration: Moral Considerations, in "Origins: NC News Service" 21 (January 30, 1992) 547, the Bishops of Pennsylvania ably summarize the different ways of supplying nourishment to the unconscious. First of all, such persons, even including those in the "persistent vegetative state," can be fed orally provided that the swallowing reflex is sufficiently unimpaired. However, those caring for them will at times prefer not to use this method even when it can be used because it can be so terribly time-consuming for care-givers who may already have many patients to care for. There are then two basic methods of feeding these patients artificially: enteral and parenteral. The Bishops describe enteral and parenteral methods as follows: "Enteral (within the bowel) feeding means that the nourishment is placed directly into the upper end of the small intestine. This can be accomplished by means of a nasogastric (through the nose and into the stomach) or nasoduodenal (through the nose and into the upper end of the small bowel) tube or it can also be done through a gastronomy (an opening directly into the stomach) or jejunostomy (an opening into the upper part of the small bowel). This method does not usually result in complications, and even if some complications do arise, they are usually not of a serious nature, but the method does presuppose that the gastrointestinal tract is intact and functioning. Parenteral (outside the bowel) feeding refers to the supplying of nourishment intravenously. This may be done when the gastrointestinal tract is not intact or does not function. It may be accomplished for a short time by means of tubes inserted into the peripheral veins (e.g., in the arms or legs), but this can easily lead to thrombosis (clotting). Therefore, if it is to be used for longer periods, it is done by inserting a tube into the central nervous system....This method of nutrition carries with it greater risks of complications."
The Pennsylvania Bishops inform their readers that they have here summarized information on tubal feeding set forth in standard medical texts such as The Merck Manual of Diagnosis and Therapy, Robert Berkow, M.D., ed. (15th ed.: Rahway, N.J.: Merck Sharp and Dohme Research Laboratories, 1987), pp. 904-911.
5Here I will briefly summarize the positions taken by representative bishops of the United States, either as individuals or as members of state or national conferences.
Statements on the matter representative of individual bishops are those of (1) The Most Reverend Louis Gelineau Bishop of Providence, R.I., and (2) The Most Reverend James McHugh, Bishop of Camden, N.J. Bishop Gelineau issued a statement, On Removing Nutrition and Water from Comatose Woman (January 10, 1988; printed in "Origins: NC News Service" 17 (January 21, 1988) 546-547) in which he declared that "the medical treatments which are being provided the patient, even those which are supplying nutrition and hydration artificially, offer no reasonable hope of benefit to her. This lack of reasonable hope or benefit renders the artificially invasive medical treatments futile and thus extraordinary, disproportionate and unduly burdensome," and consequently it would be morally permissible to stop providing food by these artificial means (547). Bishop McHugh, in a letter to priests of his diocese entitled Artificially Assisted Nutrition and Hydration (September 21, 1989; reprinted in "Origins: NC News Service" 19 (October 12, 1989) 314-316) in which he taught that artificially providing food to "unconscious, non-dying persons" (and this is the status of individuals in the "persistent vegetative state") is morally required "absent any other indication of a definite burden for the patient" (316).
Statements representative of a committee of the National Conference of Catholic Bishops and of state conferences of Catholic Bishops are the following:
(1) National Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services (Washington, D.C.: United States Catholic Conference, 1995), directive 58: "There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient."
(2) U.S. Bishops Pro-Life Committee, "Nutrition and Hydration: Moral and Pastoral Reflections" (April 2 1992) in "Origins: NC News Service" 21 (April 9, 1992) 705-712. This document concluded: "We hold for a presumption in favor of providing medically assisted nutrition and hydration to patients who need it, which presumption would yield in cases where such procedures have no medically reasonable hope of sustaining life or pose excessive risks or burdens" (at 711).
(3) New Jersey State Catholic Conference, Friend-of-court Brief to New Jersey Supreme Court, entitled Providing Food and Fluids to Severely Brain Damaged Patients" (November 3, 1987) in "Origins: NC News Service" 16 (1987) 582-584. The N.J. Bishops concluded that "nutrition and hydration are basic to human life and consequently must always be provided to a patient" (584).
(4) Texas Conference of Catholic Bishops, On Withdrawing Artificial Nutrition and Hydration (May 7, 1990) in "Origins: NC News Service" 20 (1990) 53-55. This document came to a conclusion opposite to that reached by the Pennsylvania Bishops and the U.S. Bishops Pro-Life Committee. These bishops judged that forgoing or withdrawing of artificial nutrition and hydration from a permanently unconscious person, whom they judged "stricken with a lethal pathology which, without artificial nutrition and hydration, will lead to death," is "simply accepting the fact that the person has come to the end of his or her pilgrimage and should not be impeded [by continuing the artificial feeding] from taking the final step" (54). It is to be noted that 2 of the 18 bishop members of the Texas Conference refused to sign the document.
(5) Pennsylvania Conference of Catholic Bishops, Nutrition and Hydration: Moral Considerations (January 14, 1992) in "Origins: NC News Service" 21 (January 30, 1992) 542-553. The Pennsylvania Bishops, whose document is by far the most extensive and carefully prepared and annotated, declare at the end of their study: "As a general conclusion, in almost every instance there is an obligation to continue supplying nutrition and hydration to the unconscious patient. There are situations in which this is not the case, but those are the exceptions and should not be made into the rule" (550).
Other U.S. Bishops and conferences (e.g., the Conferences of Washington, Florida, and Bishop John Myer of Peoria) have likewise issued documents on this question, but those noted here are representative.
6See William E. May, Robert Barry, Orville Griese, Germain Grisez, Brian Johnstone, Thomas J. Marzen, Bishop James T. McHugh, Gilbert Meilaender, Mark Siegler, William B. Smith, Feeding and Hydrating the Permanently Unconscious and Other Vulnerable Persons, in "Issues in Law & Medicine" 3 (Winter, 1987) 203-217.
7Pope Pius XII, The Prolongation of Life: Allocution to the International Congress of Anesthesiologists (November 24, 1957), in "The Pope Speaks" 4 (1958) 396.
8Congregation for the Doctrine of the Faith, Declaration on Euthanasia, sect. IV.
9Ibid.
10Ibid.
11See the following: Kevin O'Rourke, OP, Evolution of Church Teaching on the Prolongation of Life, in "Health Progress" 69 (January-February 1988) 28-35; The A.M.A. and Tube Feeding, in "Parameters in Health Care" 10 (Winter, 1985) 8-11; The A.M.A. Statement on Tube Feeding: An Ethical Analysis, "America" 155 (November 22, 1986) 321-323, 331 (an essay reprinted by the Society for the Right to Die, an advocacy group for legalizing euthanasia, in its newsletter); Different Viewpoints: Should Nutrition and Hydration Be Provided to Permanently Unconscious and Other Mentally Disabled Persons? in "Issues in Law & Medicine" 5 (1989) 181-196; Open Letter to Bishop McHugh: Father Kevin O'Rourke on Hydration and Nutrition, in "Origins: NC News Service" 19 (October 26, 1989) 351-352.
12See James Walter, Food and Water: An Ethical Burden in "Commonweal" (November 21, 1986) 616-619; James Walter and Thomas A. Shannon, The PVS Patient and the Foregoing/Withdrawing of Medical Nutrition and Hydration in "Theological Studies" 49 (1988) 623-647.
13O'Rourke, Evolution of Church Teaching on the Prolongation of Life, 32.
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