Why So Long to Make a Decision?

by Basil Cole, O.P.

Recently, John Paul II gave a speech to the participants of an international meeting held at the Augustinianum in Rome on the question of the vegetative state.¹ Until his speech, he had not made a ruling on the question of what to do with people who have been unconscious for many years, other than to assert, from time to time in addressing various bishops, that ordinarily feeding and hydration are to be given, even if done so artificially. Were not these references adequate enough to indicate to bishops and theologians that one should not withdraw food and hydration from people who are unconscious for over a year? Not really, because many theologians and doctors who followed them argued that being in the vegetative state is in essence to be at the door of imminent death since a person cannot chew. Therefore, feeding and hydrating them artificially is prolonging their death or using such a method as artificial feeding and hydration is extraordinary means of medical care since it is not natural feeding. If artificial oxygen can be withdrawn from patients when they are dying or when there is no hope of recovery, then feeding tubes can be withdrawn when there is no hope of returning to a normal life either. Moreover they can no longer feed themselves nor exercise their higher functions. On reflection, no one wants to linger for years unconsciously and be a burden on family or the state in this near death or limbo-like condition. Therefore it seemed reasonable to take the tubes out of a person so that he or she could die and go on to their final destination after death.

Likewise, if the principle that the lower functions are oriented to the higher functions of the human person, keeping these people alive with no reasonable hope of coming back to the conscious state is cruel and unusual punishment. It is a form of vitalism or life for life's sake to continue their care as if living for its own sake is an absolute value. The Catechism expresses this in a similar idea (2289): "If morality requires respect for the life of the body, it does not make it an absolute value." But to keep these poor human beings alive with no hope of cure or returning to their normal life seems to suggest that Catholics do not believe in an afterlife.

Theologians further argued that to withdraw their feeding and hydrating tubes is not euthanasia because one does not intend to kill anyone nor does their starvation and lack of water kill them. Their condition is the cause of death.

These arguments — in summary form from many theologians, one bishop conference (Texas) and many healthcare specialists throughout the world — essentially followed these foregoing conclusions, notwithstanding the arguments from the other theologians and philosophers who thought that these people in the vegetative state deserve better. The official Church dicasteries or the Pope let these two contradictory opinions guide many Catholic hospitals without intervening in the dispute because it was not yet clear to the Magisterium who was right. Now however the Holy Father has essentially come down against the removal of tubes, contrary to a majority of theologians.

When it comes to bioethical issues, Jesus Christ left no specific instructions or revelations. Therefore, theologians and the Magisterium must ponder from the deposit of faith and morals, which principles apply. It necessarily takes a great deal of time for the Church to understand complex problems of medicine since the latter deals with facts and the former deals with principles. Medical facts require a great deal of experience, time and observation to get to know the implications of what is happening to a person who is in a profound state of coma. Once it appears that the facts are understood correctly, then the Magisterium can make a determination of what is the truth of the matter morally, or what should be done or avoided.

Getting to the heart of the pope's short speech, we note that John Paul II deplores the use of the phrase, "vegetative state," a terminology used by physicians about a person who "gives no evident signs of self-consciousness or awareness of his or her surroundings" (#2), which has lasted a prolonged period of time usually after one or two years, depending upon the doctor's diagnosis. Some hospitals claimed a shorter period was sufficient to qualify for the "vegetative state." Further, the pope states: "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'" (#3b).

In the next series of paragraphs, John Paul counters the conclusions of the arguments mentioned above when he asserts:

The sick person in a vegetative state awaiting recovery or a natural end still has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.) and to the prevention of complications related to his confinement to bed. He also has the right to appropriate rehabilitative care and to be monitored for clinical signs of possible recovery (4b).

In this paragraph, the pope is maintaining a natural right of the unconscious person in keeping with the fundamental inclination to exist, which is taught by St. Thomas Aquinas and Germain Grisez as the basis for health care in the first place. One can notice in this small paragraph that there are four rights: care, prevention of complications, rehabilitation and monitoring for possible recovery, all of which would not have been a problem before the 1960s when life issues and advances in medicine were not so complex or in seeming conflict.

Second, the pope refines some very basic ideas on preserving life when he asserts:

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. Its use, furthermore, should be considered in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering (4c).

Here the Pope clarifies that even though artificial means are used to feed and hydrate someone, they are at the same time natural for keeping people alive not medical per se. This is an important distinction to make so that one cannot say that being medical, it is therefore extraordinary and disproportionate and so not morally obligatory. In other words, food and drink are specifically not medications and should not be treated as such.

The next paragraph refutes the notion that this kind of care is extraordinary or disproportionate:

The obligation to provide "normal care due to the sick in such cases" (Congregation for the Doctrine of faith, Jura et Bona, p. IV) includes, in fact, the use of nutrition and hydration (cfr. Pont. Cons. "Cor Unum," Dans le cadre, 2.4.4; Pont. Cons. Past. Operat. Sanit., Carta delgi Operatori Sanitari, n. 120) . . . (4d).

At this point it is necessary and helpful to cite the exact text of the Cor Unum Council, referred to by the Pope, n.2.4.4:

Earthly life is a fundamental but not absolute good. Hence the limits of the obligations to keep a person alive must be specified. The distinction already outlined between 'proportionate' means, which must never be renounced so as not to anticipate or cause death (emphasis mine), and 'disproportionate' means, which can be and, so as not to fall into therapeutic tyranny, must be renounced, is a decisive ethical criterion for specifying these limits.

Here the healthcare worker finds a meaningful and reassuring guideline for the solution of the complex cases entrusted to his responsibility. We are thinking in particular of states of permanent and irreversible coma, of tumorous pathologies with unhappy prognosis, of the aged in grave and terminal states of life (taken from footnote 235 of the Charter for Healthcare Workers).

So also, number 120 of the Charter for Healthcare Workers previously referenced in this paragraph needs to be cited:

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 (emphasis mine). 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.

Without becoming overly extreme, the Charter teaches that artificial feeding and hydration are a normal right for the patient when they are not burdensome to him. Today, there are medical instruments, which can measure signs of burden in the patient. Otherwise, "undue suspension" would be a violation of a person's right to life and would be killing the person.

From within these two important citations, the Pope will continue to draw the line and set the limits of withdrawing food and drink for those in the vegetative state when in that same paragraph 4d he says:

The evaluation of probabilities, founded on the waning hopes for recovery when the vegetative state is prolonged beyond a year, cannot ethically justify the cessation or interruption of minimal care for the patient, including nutrition and hydration. Death by starvation or dehydration 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.

Here the Holy Father is relying upon experts' experiences of those in the vegetative state when he says "scant hope of recovery." Nevertheless, even they have a right to minimal care, feeding and hydration. This will not cure them but to forgo this least of care is to kill them, which is a form of euthanasia by omission. It took a great deal of time to understand this because it was not clear at first if this was ordinary or extraordinary means of health care and it may not have been so clear that these people are not in a state of "imminent death."

In paragraph 4e, John Paul develops further the theme of euthanasia:

In this regard, I recall what I wrote in the Encyclical Evangelium Vitae, making it clear that "by euthanasia in the true and proper sense must be understood an action or omission which by its very nature and intention brings about death with the purpose of eliminating all pain"; such an act is always "a serious violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person" (n. 65).

Here it must be said that evaluating the evil of euthanasia, not only is the immediate intention to be taken into account but also the very nature of the act must be analyzed. Even immediate intentions do not always specify a moral species. Some acts of themselves directly kill either by commission or omission, which the pope is explicitly drawing our attention to. However, it is well known among medical personnel that when someone is imminently dying, feeding adds to pain which usually flows from cancer and the like. When food and drink is then withdrawn, it is only indirectly, not if its nature, aiding in killing a person because it is only accidentally contributing to the death of a person who is perhaps dying from cancer or a brain tumor.

With this significant document the Holy Father has definitively spoken, even though not by an encyclical letter. Many ethical concerns are laid to rest and those theologians who held a different view need to come on board by admitting their erroneous opinions and continue to write with Mother Church, not against her.

End Notes

1 Address of John Paul II to the participants in the International Congress on "Life Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas" Saturday, 20 March, 2004, located on 22 October 2004 at: http://www.vatican.va/holy_father/john_paul_ii/speeches/2004/march/index_en.htm.

Reverend Basil Cole, O.P., for many years has been teaching theology in Rome and in the USA. He belongs to the Western Province of the Dominicans and as a member of their mission band has preached many parish retreats. He is the author of several books and many articles.

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