Statement Concerning the Case of Theresa Schiavo
Introduction
When people struggling with a moral or legal problem raise the question whether any teachings of the Catholic Church have bearing on their problem, a Catholic who undertakes to supply an answer assumes a serious responsibility. The task of stating relevant Church doctrine and explaining how it bears on a contested case is often a non-trivial matter. If the person undertaking the task happens to be a Catholic priest, the obligations accepted are clearly quite stringent. And, if the context in which the problem arises is a legal proceeding in which a human life hangs in the balance, then those obligations assume the utmost stringency.
In the legal proceedings concerning the fate of Theresa Schiavo, a Catholic priest has undertaken to state relevant Church teachings and to give their bearing on the case. Some people following the case are convinced that there are grave flaws in Father Gerard Murphy's handling of Church teachings. They invited us to give a sounder account of relevant Catholic doctrine and to comment on Father Murphy's testimony. If a human life were not hanging in the balance, we would be disinclined to accept the invitation, disinclined to fault the testimony of a Catholic priest. But, a human life is at stake, so we have accepted the invitation. Upon examining Father Murphy's testimony and other materials concerning the Schiavo case, we have reached the conclusion that the representations he made are in certain important respects inaccurate. We record this judgment without in any way calling into question either the honor or good will of Father Murphy. What is at issue is a sharp disagreement concerning Church doctrine. We have no reason to suppose that Father Murphy approached his task with any less good will or resolve to do right than we bring to our own.
This age has witnessed the wholesale destruction of traditional protections of human life, and, in the midst of social upheaval and moral vandalism, the Catholic Church has often served as the last bastion of defense for the most vulnerable among us: the unborn, the disabled, and the gravely ill. There are, thus, two important reasons to regret the existence of misrepresentations of her teachings (however unwitting and well-intentioned) when those misrepresentations smooth the way to lethal action against a particular vulnerable person: there is, first, the regrettable circumstance that the vulnerable person may die as a direct result of the misrepresentations; but there is also the even graver danger that the distorted testimony will be cited in future proceedings by individuals pleased to seize an opportunity to lend the moral authority of the Catholic Church to efforts to bring about the deaths of other innocent persons.
Since Father Murphy's testimony is preceded by pages devoted to the training and experience deemed to qualify him to testify concerning the case, it will not be amiss for us to devote a paragraph to our own credentials and experience. One of us (JMD), a Catholic who holds a doctorate in philosophy from Stanford University, is Morse-Alumni Distinguished Teaching Professor of Philosophy at the University of Minnesota and co-founder and former co-chair of a medical ethics program at the University of Minnesota's medical school. Professor Dolan has been involved in medical ethics at both scholarly and practical levels for three decades. He served for three years as a member of the University of Minnesota's Institutional Review Board for medical experiments involving human subjects and for more than ten as advisor to the Nursing Home Action Group. He has often been called upon by physicians and families to offer counsel in difficult cases. In addition to teaching philosophy, mathematics, and logic at MIT, the University of Chicago, the Rockefeller University, Swarthmore College and other schools, Professor Dolan has taught medical ethics at the Mayo Clinic, the graduate school of the University of Minnesota, and the medical school of the University of Minnesota. He has published on the subject in law reviews and medical journals and has given countless invited addresses on medical ethics at universities, conferences, research institutes, and medical schools across the United States and in Japan. (At several places in the present statement, we draw on his article "Death by Deliberate Dehydration and Starvation: Silent Echoes of the Hungerhäuser," Issues in Law and Medicine, Vol. 7, No. 2, Fall, 1991). The other author (KLF), a Catholic priest and scholar, holds a Licentiate in Sacred Theology and two degrees, including a doctorate in philosophy, from the University of Oxford. Father Flannery is a member of the Society of Jesus (the Jesuits) and dean of the philosophy faculty at the Pontifical Gregorian University in Rome. Among his publications are a number on moral philosophy, including an entire book devoted to the subject: Acts Amid Precepts: The Aristotelian Logical Structure Of Thomas Aquinas's Moral Theory, Catholic University of America Press. As a full professor in a pontifical (i.e., papal) faculty, he has received the explicit nihil obstat of the Vatican (i.e., the declaration that the Vatican finds his writings consistent with the Catholic Faith). He is often consulted by the Vatican regarding ethical questions.
We note at the outset our opinion that the moral considerations and reflections required to settle the question whether Theresa Schiavo's food and water can be cut off are available to any person who calls upon the natural powers of moral reflection available to us all. Pope John II writes:
The Gospel of life is not for believers alone: it is for everyone. The issue of life and its defence and promotion is not a concern of Christians alone. Although faith provides special light and strength, this question arises in every human conscience which seeks the truth and which cares about the future of humanity. Life certainly has a sacred and religious value, but in no way is that value a concern only of believers. The value at stake is one which every human being can grasp by the light of reason; thus it necessarily concerns everyone. Evangelium Vitae, § 101, par. 2 (emphasis in original)
We believe that an individual who has never studied the specific doctrines of the Church is capable of the moral discernment that, with the exception of an extremely narrow class of special cases, it is always a grave wrong to cut off the food and water of a person who is severely disabled and unable to defend herself. We are confident, also, that the light of ordinary moral reason is sufficient to enable an honest and deliberate moral agent (not in the thrall of the euthanasiast impulse of the age) to discern that Theresa Schiavo's circumstances do not fall into the narrow class of exceptions just mentioned. But the invitation we have accepted asks us to identify teachings of the Catholic Church that bear on the case of Theresa Schiavo and to explain their bearing. And we turn now to that task.
Relevant Catholic Doctrine
The first relevant teaching, central to the entire Judeo-Christian tradition, is the familiar commandment:
Thou shalt do no murder.
This is sometimes mistranslated (e.g., in the King James version) as "Thou shalt not kill" (leading superficial critics to announce with glee that traditional religion contradicts itself by holding simultaneously, first, that all killing is wrong and, second, that the death penalty and just wars are morally permissible). But the commandment prohibits murder, not all killing, and the central core of application of the concept of murder is deliberate lethal action against an innocent person. The term "innocent" as it figures here, means simply "not harming." Thus, someone who is assaulting another person is not innocent in the relevant sense, and someone found guilty of a capital offense by due process of law might also not be innocent in the relevant sense. Persons who are not innocent are also protected by the prohibition against murder: it is possible to murder a person who is not innocent. But, the application of the prohibition to the case of the non-innocent involves complications that have no relevance to the present deliberations. It remains true that the central core of application of the concept of "murder" -- the clearest instance of murder -- is the deliberate killing of the innocent. The specific case we are addressing here, the fate of Theresa Schiavo, concerns a person who is plainly innocent.
The full import and power of the prohibition against murder is spelled out in numerous official Church documents. Thus, for example, we find the following formulation in a declaration of the Sacred Congregation for the Doctrine of the Faith:
No one can make an attempt on the life of an innocent person without opposing God's love of that person, without violating a fundamental right and therefore without committing a crime of utmost gravity. (Declaration on Euthanasia, 5 May 1980)
Later in the same document, the Congregation is even more painstakingly explicit on this point.
It is necessary to state firmly once more that nothing and no one can in any way permit the killing of an innocent human being, whether a fetus or an embryo, an infant or an adult, an old person, or one suffering from an incurable disease, or a person who is dying. (Declaration on Euthanasia, par. 5)
The circumstance that a person is extremely ill or severely disabled or even dying does not remove that person from the protection of the commandment against murder. In the "Gospel of Life" and numerous other writings, the Holy Father has made crystal clear the "absolute inviolability" of innocent human life.
If such great care must be taken to respect every life, even that of criminals and unjust aggressors, the commandment, "You shall not kill" has absolute value when it refers to the innocent person. And all the more so in the case of the weak and defenseless human being,... In effect , the absolute inviolability of innocent human life is a moral truth, clearly taught by Sacred Scriptures, constantly upheld in the Church's tradition and consistently proposed by her Magisterium." (Evangelium Vitae, § 57, pars. 1 and 2).
As the extract just quoted makes clear, it is possible to multiply indefinitely passages in which the teaching in question is asserted.
Another relevant teaching of the Catholic Church is a principle put forward by St. Thomas Aquinas. In G. E. M. Anscombe's concise paraphrase: "A [harm by omission] is voluntary ... [if] it was both possible and necessary for the agent to act and he did not." ("Murder and the Morality of Euthanasia," Euthanasia and Clinical Practice: Trends, Principles, and Alternatives, Chapter III, The Linacre Centre, 1982) The extreme compression of this formulation may prevent some readers from appreciating it. To give a fuller statement of the content of St. Thomas's principle and to make clear how it bears on the specific harm of causing death by omission, we offer the following more explicit formulation: A deliberate omission that causes death is morally an act of intentional killing when three conditions are satisfied: (i) It is within the agent's power to supply what is being withheld, (ii) The agent has an obligation to supply it. (iii) The agent understands that withholding what is needed is likely to cause death.
It is worth considering this principle's bearing on the case of Theresa Schiavo. Those responsible for her care certainly have the capacity to supply nourishment to her. Her parents and siblings assert (correctly in our judgment) that they have an obligation to supply nourishment to her. Finally, every party to the case understands clearly that withholding nourishment from Theresa Schiavo will certainly result in her death. It follows that deliberately withholding nourishment from Theresa Schiavo would count morally as intentionally killing her. Since the killing in question would be the intentional killing of an innocent person, it would be murder.
Now the crucial step in this application of Aquinas's principle to the case of Theresa Schiavo is the second one, the step at which we endorse her family's assertion that her care givers have an obligation to supply her with nourishment. We endorse this assertion as in accordance with the consistent teaching of virtually all traditional Catholic philosophers and theologians, including Thomas Aquinas, that to give food to a hungry person is an inherently good thing and its opposite (starvation) an evil [Thomas Aquinas, De malo q.2 a.4 ad 5]. The non-prevention of an evil (when such prevention is possible) is itself evil [Thomas Aquinas, Summa theologiae I-II q.71 a 5]; therefore, we are obliged to provide nutrition and hydration to people in need of them if this is within our power (and provided, of course, that administering the nutrition and hydration would itself not cause lethal harm to the person in question or be utterly futile). Father Murphy does not hold this position; he is not alone among medical ethicists. In this age of widespread support for assisted suicide and euthanasia, a number of medical ethicists would concur with Father Murphy's denial of step two. One can even find statements by Church committees that deny step two. The existence of these statements shows that there is disagreement among Catholics concerning the application of Catholic doctrine to the present case. The existence of disagreement does not by itself establish that there is no clear application of Church teachings to a case. It merely shows that some Catholics disagree with others. One can find people who describe themselves as "Catholic" who reject the teachings of Humanae Vitae concerning sexual ethics. One can even find people who describe themselves as "Catholic" who reject the Church's teaching that induced abortion is a grave wrong. No one would conclude from this that there is uncertainty concerning the Church's teachings concerning sexual morality or abortion. Before turning to consider some of the dissenting statements just alluded to, we wish to emphasize two points concerning these statements. First, they do not emanate from the most authoritative sources in the Magisterium. They are issued by state Catholic conferences and individual clerics, not by bodies as authoritative as the Sacred Congregation for the Doctrine of the Faith or the Pope himself. Second, these statements are explicitly contradicted by a number of other statements from sources at the same level of the Magisterium from which they proceed. Before we turn to these various statements, we give brief consideration to the question whether there is an advanced directive relevant to the present deliberations.
Is there an Advance Directive that has Bearing on this Case?
Three points bear on the answer to this question. First, Theresa Schiavo left no written advanced directive. Second, the claim that she left oral instructions which have the force of a written advance directive rests on thin and dubious evidence. Third, even if she had left explicit instructions that those responsible for her care should cut off her food and water in the present circumstances, there would be large moral obstacles to acting on those instructions. We take these points up in turn.
The first requires no elaboration. All parties to the case agree that Theresa left no written advance directives.
Next, the thinness and dubiousness of the evidence concerning her past expressions of her wishes. Theresa Schiavo's husband now states that she said she would not want to be kept alive if she were dependent on others. Several difficulties attend this claim. First, he did not make it when proceedings were underway which resulted in a $700,000 settlement for the purpose of funding her future care. Second, he is her potential heir and stands to inherits what remains of the settlement at her death, a circumstance which could possibly color his present recollections of statements she made years ago. (Very recently, two persons have come forward to testify that they heard Theresa Schiavo make a statement like the one her husband says he heard, but these persons waited years before announcing their news and both are relatives of Theresa's husband, his sister and brother-in-law.) Third, even if it were certain that Theresa Schiavo made a remark to the effect that she would rather be dead than severely disabled, reasonable questions could be raised as to whether the remark represented some considered view of hers or was merely a casual comment to which no weight should be attached. More than one person has uttered in the course of a particularly bad day "I wish I were dead!", but it would be a grave mistake to take such an outburst seriously, much less to act on it, carrying out steps to bring about the person's death. Further, even if it could be established that Theresa Schiavo's considered conviction was that she would prefer death to a life of severe disability, it would not follow that this Catholic woman wanted others to kill her if she became disabled. Still less would it follow that she had consented in advance to have others bring about her death by deliberate dehydration and starvation. It is improbable that a Catholic would give advance instructions to others to kill her if she became gravely disabled. It is even more improbable that any rational agent (whatever his or her beliefs) would ask in advance for a death caused by dehydration and starvation, a method veterinarians properly refuse to employ when they are "putting down" non-human animals.
Finally, the important moral obstacles to bringing about a person's death by deliberate dehydration and starvation even if the person asked for such a death. Even if it could be established, contrary to rational expectation, that Theresa Schiavo's considered moral view was that she should be denied food and water if she ever became seriously disabled, it would not follow that anyone has the authority to bring about her death her by any method. An advanced directive can be acted on only if the actions it requests are in accord with the dictates of justice and morality. Plainly, if she asked in advance that a lethal injection be administered should her quality of life fall below some predetermined measure of quality of life, it would be neither morally nor legally permissible to honor her request. But, is it clear that a request to have one's death brought about by dehydration and starvation is any less problematic than a request to have one's death brought about by lethal injection?
We have been concerned in this section with a single question: "Is there an advance directive that has bearing on the conflict over Theresa Schiavo's care?" The meagerness and problematic character of the evidence that Theresa ever said anything relevant to the present deliberations, and the moral obstacles to acting on instructions to cause death by deliberate dehydration and starvation, even if such instructions did exist, make it clear that the answer to this question is "No."
Does a State of Persistent Unconsciousness Relieve One's Care Givers of The Obligation to Supply the Normal Care Owed to a Sick Person?
We now take up the task of examining some conflicting views Catholic theologians have expressed concerning our obligations to the permanently unconscious. We note, at the outset, that credible medical testimony has been presented to the court supporting the clinical judgment that Theresa Schiavo is not in a state of prolonged unconsciousness. We were not asked to reach a judgment about the accuracy or inaccuracy of this testimony or of any competing clinical evaluation before the court. Our task is say what bearing the teachings of the Catholic Church have on Theresa Schiavo's case, and we propose to do so, while operating under the assumption that the most unfavorable medical diagnosis of her condition is correct. That is, for the purposes of the present analysis we adopt the working postulate that Theresa Schiavo is in a persistent state of unconsciousness from which she will never recover. Adopting this postulate or stipulation in no way reflects a judgment on our part concerning the actual medical facts of the case. We are aware of the uncertainties attending clinical prognostication. We know that a "diagnosis" which states that a patient will not recover from a state of unconsciousness is a prognostication, a necessarily uncertain prediction of the future. Our aim is to spell out the bearing of the Church teachings on Theresa Schiavo's circumstances under the assumption that she is in "a persistent vegetative state."
We begin our analysis with the observation that there are countless contexts in which it is entirely licit, fully in accordance with the teachings of the Catholic Church, to withhold or discontinue a life-sustaining treatment. Both the Catechism of the Catholic Church and the Sacred Congregation for the Doctrine of the Faith teach the moral permissibility of such withholding or withdrawal of treatment. Thus, the Catechism says:
Discontinuing medical procedures that are burdensome, dangerous, extraordinary or disproportionate to the expected outcome can be legitimate. It is the refusal of "overzealous" treatment. Here one does not will to cause death; one's inability to impede it is merely accepted. The decision should be made by the patient if he is competent and able, or if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected. (Number 2278)
It is manifestly clear that providing Theresa Schiavo with nourishment is neither burdensome, dangerous, nor extraordinary. There are ethicists who would wish to argue that giving her food and water is "is disproportionate to the expected outcome." But the result of giving Theresa food and water is that she is able to continue to live. The (relatively modest) effort required to supply her with food and water can be characterized as "disproportionate to the expected outcome," namely, her continuing to live, only by extending implicit approval of the doctrine that some human lives are unworthy of continued existence. (The circumstance that the doctrine of "Lebens unwertesleben" was central to reasoning of Hoche and Binding, who had important influence on Nazi practice, ought to give pause to any ethicist inclined to claim that giving Theresa Schiavo food and water is "disproportionate to the expected outcome.") "Very often the worst threat to a good ‘quality of life' for these people is not the disability itself, but the prejudicial attitudes of others--attitudes based on the idea that a life with serious disabilities is not worth living." ("Nutrition and Hydration: Moral and Pastoral Reflections," Resource Paper, Committee for Pro-Life Activities, United States Conference of Catholic Bishops [formerly known as the National Conference of Catholic Bishops], 1992)
Concerning the topic of withholding or withdrawing care, the Congregation for the Doctrine of the Faith offers the following instruction:
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. In such circumstances the doctor has no reason to reproach himself with failing to help the person in danger. (Declaration on Euthanasia, 1985)
It is worth making three observations concerning the bearing of this instruction on Theresa Schiavo's case. First, it allows withholding a specific treatment if it would "only secure a precarious" life. But, all of the medical claims we have seen in this case agree that there is nothing precarious about Theresa Schiavo's state, that she is in a stable condition, that she is not on the verge of death. Indeed, if her potential heir believed that Theresa were about to die, it is unlikely that he would be engaged in a legal struggle to cut off her food and water. Second, it also allows withdrawing or withholding a treatment if it would secure only "a burdensome prolongation of life," but on the most gloomy diagnosis of Theresa Schiavo's situation -- the one under which we are operating -- she is in a peaceful sleep, hardly a burdensome state. Third, the Sacred Congregation allows a treatment to be withheld "so long as the normal care due to the sick person in similar cases is not interrupted," but it is certainly more reasonable to view the provision of food and water, whether supplied through a tube or not, as "normal care," rather than medical treatment.
Now the question before us in the present section is whether prolonged unconsciousness constitutes a disability so extreme that one's care givers are relieved of their obligation to supply the normal care owed to a sick person. As we have noted, Catholic bodies less authoritative than the Sacred Congregation for the Doctrine of the Faith and the Pope have addressed the specific case of prolonged unconsciousness. Some have arrived at conclusions we find entirely in accordance with the Church's teachings concerning respect for innocent human life. Others have come up with conclusions that strike us as at odds with Church teachings. We turn now to consideration of claims and judgments put forward by these bodies.
We note, first, a directive put forward by the United States Conference of Catholic Bishops. It is directive 58 in the most recent edition of their "Ethical and Religious Directives for Catholic Health Care Services":
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. ("Ethical and Religious Directives for Catholic Health Care Services," Fourth Edition, 2001)
It is a merit of this formulation that it confines the "burdens" to be taken into account to those borne by the patient. We have already noted that Theresa Schiavo is, on the most pessimistic assessment of her condition, in a state of peaceful sleep and, thus, bears no burdens as a result of continued nourishment. This directive is plainly in full accordance with the teachings of bodies higher in the Magisterium.
In another document from the United States Conference of Catholic Bishops, the 1992 "Resource Paper" we quoted above, we find the following question and response:
6. Do persistently unconscious patients represent a special case?Even Catholics who accept the same basic moral principles may strongly disagree on how to apply them to patients who appear to be persistently unconscious -- that is, those who are in a permanent coma or a "persistent vegetative state" (PVS). ... Some moral questions in this area have not been explicitly resolved by the Church's teaching authority. ("Nutrition and Hydration: Moral and Pastoral Reflections," hereafter N&H)
There is disagreement in some quarters concerning the proper moral response to persons who are "persistently unconscious." We have already registered our opinion that the mere existence of such disagreement does not by itself preclude there being a moral response dictated by the teachings of the Church. We do not quarrel with the further observation by the committee members that "Some moral questions in this area have not been explicitly resolved by the Church's teaching authority." The very wording chosen "not ... explicitly resolved" is an acknowledgment that the questions may be already implicitly answered by the authority of the Church. The absence of an explicit resolution is entirely consistent with the existence of an implicit resolution dictated by the "Church's teaching authority," much as theorems are dictated by the axioms of a formal theory.
The committee members claim "wide agreement among Catholic theologians" for two additional points concerning patients in a state of chronic unconsciousness. The first of these reads as follows:
1. An unconscious patient must be treated as a living human person with inherent dignity and value. Direct killing of such a patient is as morally reprehensible as the direct killing of anyone else. Even the medical terminology used to describe these patients as "vegetative" unfortunately tends to obscure this vitally important point, inviting speculation that a patient in this state is a "vegetable" or a subhuman animal. (N&H)
There is undoubtedly widespread agreement among Catholic theologians and moral philosophers on this point (including the valuable observation about the term ‘vegetative"). But, reasonable doubts can be recorded concerning the second point for which the committee members claim widespread agreement:
2. The area of legitimate controversy does not concern patients with conditions like mental retardation, senility, dementia or even temporary unconsciousness. Where serious disagreement begins is with the patient who has been diagnosed as completely and permanently unconscious after careful testing over a period of weeks or months. (N&H)
Characterizing the debate over permanently unconscious" patients as an "area of legitimate controversy" reveals the committee's impression that the teaching authority of the Church leaves open the question whether or not it is permissible to cut off the food and water of a person judged permanently unconscious. They proceed to quote a rather astonishing argument in favor of withholding care from the unconscious:
Some moral theologians argue that a particular form of care or treatment is morally obligatory only when its benefits outweigh its burdens to a patient or the care providers. In weighing burdens, they say, the total burden of a procedure and the consequent requirements of care must be taken into account. If no benefit can be demonstrated, the procedure, whatever its burdens, cannot be obligatory. These moralists also hold that the chief criterion to determine the benefit of a procedure cannot be merely that it prolongs physical life, since physical life is not an absolute good but is relative to the spiritual good of the person. They assert that the spiritual good of the person is union with God, which can be advanced only by human acts, i.e., conscious, free acts. Since the best current medical opinion holds that persons in the persistent vegetative state (PVS) are incapable now or in the future of conscious, free human acts, these moralists conclude that, when careful diagnosis verifies this condition, it is not obligatory to prolong life by such interventions as a respirator, antibiotics, or medically assisted hydration and nutrition. To decide to omit non-obligatory care, therefore, is not to intend the patient's death, but only to avoid the burden of the procedure. Hence, though foreseen, the patient's death is to be attributed to the patient's pathological condition and not to the omission of care. Therefore, these theologians conclude, while it is always wrong directly to intend or cause the death of such patients, the natural dying process which would have occurred without these interventions may be permitted to proceed. (N&H)
It is clear that this argument is unsound. First, the result of a sizable number of persons taking its reasoning seriously and acting on it would be moral catastrophe. Permanently unconscious persons are not the only human beings incapable of "conscious, free acts" which advance our union with God. Patients who have undergone massive strokes, Alzheimer's patients, victims of severe head injuries, persons suffering from extreme congenital mental retardation, and many other conscious persons are similarly incapacitated. If the reasoning just quoted were sound, all of these other persons would join the permanently unconscious as legitimate targets of deliberate lethal neglect. Secondly, if in the cases described in the argument food and hydration are withdrawn, it is not true that "though foreseen, the patient's death is to be attributed to the patient's pathological condition and not to the omission of care." Withdrawal of food and hydration (i.e., "omission of care") creates new pathologies not present before that action, to wit: starvation and dehydration. Yet, surprisingly, all the committee members say about this very bad argument is that "it is not theologically conclusive and we are not persuaded by it."
They proceed to paraphrase sounder reasoning put forward by Catholic moral theologians who argue
... that while particular treatments can be judged useless or burden-some, it is morally questionable and would create a dangerous precedent to imply that any human life is not a positive good or "benefit." They emphasize that while life is not the highest good, it is always and everywhere a basic good of the human person and not merely a means to other goods. They further assert that if the "burden" one is trying to relieve by discontinuing medically assisted nutrition and hydration is the burden of remaining alive in the allegedly undignified condition of PVS, such a decision is unacceptable, because one's intent is only achieved by deliberately ensuring the patient's death from malnutrition or dehydration. Finally, these moralists suggest that PVS is best seen as an extreme form of mental and physical disability -- one whose causes, nature and prognosis are as yet imperfectly understood -- and not as a terminal illness or fatal pathology from which patients should generally be allowed to die. Because the patient's life can often be sustained indefinitely by medically assisted nutrition and hydration that is not unreasonably risky or burdensome for that patient, they say, we are not dealing here with a case where "inevitable death is imminent in spite of the means used."... Rather, because the patient will die in a few days if medically assisted nutrition and hydration are discontinued,... but can often live a long time if they are provided, the inherent dignity and worth of the human person obligates us to provide this patient with care and support. (N&H)
This reasoning strikes us as fully in accord with traditional Catholic teaching concerning proper responses to persons who are sick or severely disabled. Its conclusion rings true as a characteristic Catholic moral instruction: "the inherent dignity and worth of the human person obligates us to provide this patient with care and support."
The committee members themselves proceed to make the following point.
On the one hand, there is a concern that patients and families should not be subjected to unnecessary burdens, ineffective treatments and indignities when death is approaching. On the other hand, it is important to ensure that the inherent dignity of human persons, even those who are persistently unconscious, is respected, and that no one is deprived of nutrition and hydration with the intent of bringing on his or her death. (N&H)
They add an observation about patients judged to be permanently unconscious:
We do know that many of these patients have a good prognosis for long-term survival when given medically assisted nutrition and hydration, and a certain prognosis for death otherwise -- and we know that many in our society view such an early death as a positive good for a patient in this condition. Therefore we are gravely concerned about current attitudes and policy trends in our society that would too easily dismiss patients without apparent mental faculties as non-persons or as undeserving of human care and concern. (N&H)
The committee members are led by their reflections to the following general conclusion concerning patients experiencing prolonged unconsciousness:
... it is our considered judgment that while legitimate Catholic moral debate continues, decisions about these patients should be guided by a presumption in favor of medically assisted nutrition and hydration. A decision to discontinue such measures should be made in light of a careful assessment of the burdens and benefits of nutrition and hydration for the individual patient and his or her family and community. Such measures must not be withdrawn in order to cause death, but they may be withdrawn if they offer no reasonable hope of sustaining life or pose excessive risks or burdens. We also believe that social and health care policies should be carefully framed so that these patients are not routinely classified as "terminal" or as prime candidates for the discontinuance of even minimal means of life support. (N&H)
Thus, the upshot of the "Resource Paper," the considered judgment of its authors, is that one can cut off food and water only when "they offer no reasonable hope of sustaining life or pose excessive risks or burdens." We have already noted that Theresa is not terminally ill, that supplying her with food and water will sustain her life. None of the parties to the case claims that feeding Theresa will expose her to "excessive risks." (Indeed, it is clear that the risks all lie on the other side: withholding her food and water will cause her death.) Further, it is clear that continuing Theresa's food and water will impose no burden on her or anyone else. Not on her, because on the hypothesis that she is unconscious she is not experiencing any pain. Not on her family, because a substantial sum of money has been set aside for her long-term care and because her mother and father and brother and sister have registered in the strongest terms their passionate desire for Theresa's feeding to continue. Note that both documents we have been examining state strict standards which would forbid cutting off Theresa Schiavo's food and water.
Thus, though one of the two documents from the United States Conference of Catholic Bishops, calls disagreement over the feeding of the permanently unconscious "legitimate," both defend criteria for withholding food and water that forbid cutting off Theresa Schiavo's food and water. The Resource Paper on "Nutrition and Hydration" considers an argument in favor of cutting off the food and water, but rejects it as "inconclusive." This characterization of the argument as excessively gentle. The argument, whose adoption would have lethal consequences not only for the unconscious but also for countless disabled persons who are conscious, is deeply flawed. Though neither of the documents constitutes official church teaching, both reach conclusions that protect Theresa Schiavo.
Father Murphy testifies that it would be "consistent" with Church teachings to remove Theresa's feeding tube in the present circumstances. If the authors of the 1992 Resource Paper were right to hold their belief that there is "legitimate debate" over our obligation to feed permanently unconscious persons, then Father Murphy's testimony would be correct, not in the sense that the Church would, in that case, be teaching that it is permissible to deny food and water to the unconscious, but rather in the weaker sense that the Church, under the hypothesis in question, would not have expressly forbidden such denials. But it important to note that, even though the Resource Paper authors deem the question of feeding the unconscious not explicitly resolved by Church teachings, they themselves offer strict standards for withholding nourishment from the unconscious, standards which forbid the denial of food to Theresa Schiavo. In fact, as one reviews the literature concerning the feeding of the unconscious, one discovers again and again conclusions like those advanced in the two documents from the United States Conference of Catholic Bishops. A few sources, like the authors of the Resource Paper, view the question as one not explicitly settled by official Church teachings, but, almost invariably, those same sources conclude that denial of food and water to the unconscious is wrong.
It is interesting to observe that the protective findings of the two documents from the United States Conference of Catholic Bishops are in agreement with the conclusions of groups advising the Holy See. These groups also defend the ethical judgment that permanently unconscious patients should be fed. Thus, for example, in the mid-eighties a study group of the Pontifical Academy of Sciences concluded: "If the patient is in a permanent, irreversible coma, as far as can be foreseen, treatment is not required, but all care should be lavished on him, including feeding." ("The Artificial Prolongation of Life," Pontifical Academy of Sciences, Origins, Volume 15 [December 5, 1985], page 415). Given that this conclusion concerns comatose patients, the "feeding" in question is clearly medically assisted feeding. Statements to the same effect can be found in: Pontifical Council "Cor Unum," Question of Ethics Regarding the Fatally Ill and the Dying (1981), page 9, and "Ne Euthanasia Ne Accanimento Terapeutico," La Civilta Cattolica, Volume 3280 (February 21, 1987), page 324. To be sure, one can find articles by individual priests and bishops arguing a contrary view, but this contrary view is by no means a majority opinion among Catholic theologians and is certainly not official church teaching.
Conclusion
We have seen that, while there are no documents bearing the full teaching authority of the Church that contain the literal phrases "persistent vegetative state" or "prolonged unconsciousness," the language of many documents that do have the full authority of the Church carry the powerful suggestion that persons who are unconscious deserve the same respect as any other human being. We have already seen that the Sacred Congregation for the Doctrine of the Faith teaches us that
... nothing and no one can in any way permit the killing of an innocent human being, whether a fetus or an embryo, an infant or an adult, an old person, or one suffering from an incurable disease, or a person who is dying.
We can ask ourselves which of the two following extensions of this passage better accords with its purport.
... nothing and no one can in any way permit the killing of an innocent human being, whether a fetus or an embryo, an infant or an adult, an old person, or one suffering from an incurable disease, or a person who is dying, or a person judged permanently unconscious.... nothing and no one can in any way permit the killing of an innocent human being, whether a fetus or an embryo, an infant or an adult, an old person, or one suffering from an incurable disease, or a person who is dying, but, of course, a person judged permanently unconscious is not protected by this prohibition.
It is clear that the first extension of the original passage accords better with its purport. We have also recalled Pope John II's powerful statement in Evangelium Vitae that "the absolute inviolability of innocent human life is a moral truth, clearly taught by Sacred Scriptures, constantly upheld in the Church's tradition and consistently proposed by her Magisterium."
Moreover, we have seen that bodies advising the Vatican have explicitly discussed persistently unconscious patients and recommended that, while it is permissible to withhold "medical treatment" from such a person, "all care should be lavished on him, including feeding." Though these recommendations do not have the full authority of Church teaching, their source within the Church requires us to accord them great weight. Further, we have seen that, while individual clerics offer a different view of our responsibility to unconscious patients, two documents produced by the United States Conference of Catholic Bishops advance standards of care for patients in prolonged unconsciousness which expressly forbid cutting off food and water from a patient in Theresa Schiavo's circumstances.
In light of all these facts, it is, to say the least, highly misleading to assert that it would be in accord with the teachings of the Catholic Church to cut off Theresa Schiavo's food and water. The very most that could possibly be claimed is that the Church has not expressly and explicitly forbidden cutting off the food and water of a patient judged permanently unconscious. This assertion would allow the possibility that such a denial of food and water is, nonetheless, in violation of the Church's moral instructions concerning our obligations towards innocent human life. We are convinced that this is the case.
We can summarize a few of the other principal points of our analysis with a series of questions and answers. On what ground could one possibly justify denying food and water to Theresa Schiavo? On the ground that she cannot digest and metabolize the food? If that were the case she would be on the verge of death. But she is not terminally ill, and she is fully capable of digesting and metabolizing the nourishment given her. On the ground that the life sustained is a burden to her? But those arguing for the denial of food are claiming that she is permanently unconscious and we are adopting their claim as a working hypothesis. On that hypothesis, Theresa is in a peaceful sleep and her life is no burden to her. On the ground that continuing her feeding is a burden on her family? But some funds remain from the substantial sum that was set aside for her care and her parents and siblings have expressed in unmistakable and moving terms their passionate desire that she be allowed to live. On the ground that the expected outcome of the continued feeding would be disproportionate to the effort involved in the feeding? But the judgment that sustaining the life of someone as severely disabled as Theresa is not worth the effort of feeding her is a special case of the dangerous and immoral doctrine that some human lives are not worth living, a doctrine that had its natural home and practice in Nazi Germany.
We have already expressed our judgment that it is immensely "improbable that any rational agent (whatever his or her beliefs) would ask in advance for a death caused by dehydration and starvation, a method veterinarians properly refuse to employ when they are ‘putting down' non-human animals." It is also clear to us that such a death could not possibly be in anyone's "best interests." ("They that die by famine die by inches.") For two thousand years the Church has consistently, unambiguously, and uncompromisingly insisted that the value of a human life is not conditioned by standards of fitness or competence, that every human life, however injured or compromised, possesses incalculable and inviolable worth and dignity. The life of Theresa Schiavo possesses incalculable and inviolable worth and dignity. An attempt to cut off her food and water would be attempted murder. In the words of the Catholic moral theologians cited in the 1992 Resource Paper of the United States Conference of Catholic Bishops, "the inherent dignity and worth of the human person obligates us to provide this patient with care and support."
John M. Dolan, Ph.D., Morse-Alumni Distinguished Teaching Professor of Philosophy, University of Minnesota, former Co-Chair, Program in Human Rights and Medicine, Medical School, University of Minnesota
Father Kevin Flannery, S.J., D.Phil. Dean, The Philosophy Faculty of the Pontifical Gregorian University, Rome
For more information on Terri Schiavo please visit www.terrisfight.org.
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