On Basic Care for Patients in the 'Vegetative' State
In a 2004 address on care for patients diagnosed as being in a "vegetative state," Pope John Paul II affirmed the human dignity of these patients and the obligation to provide them with ordinary care, including food and water, even with artificial assistance. On Sept. 14, 2007, through its "Responses to Certain Questions of the United States Conference of Catholic Bishops Concerning Artificial Nutrition and Hydration," the Congregation for the Doctrine of the Faith (CDF), with the approval of Pope Benedict XVI, reaffirmed and further explained this papal teaching. (The CDF's "Responses" was accompanied by a "Commentary," which offered further explanation.) The U.S. Conference of Catholic Bishops (USCCB) has welcomed this important clarification of Catholic Church teaching and has provided its own set of questions and answers to promote a better understanding of it in the United States.1
Unfortunately, confusion about this teaching and opposition to some aspects of it persist in some quarters. For example, a recent Health Progress article by John J. Hardt, Ph.D. and Fr. Kevin D. O'Rourke, OP, JCD, STM, titled, "Nutrition and Hydration: The CDF Response, In Perspective," misinterprets the Holy See's documents in important respects, and even makes the charge that the CDF interprets euthanasia in a way that is "at odds with the traditional teaching of moral theology."2
As chairmen of the U.S. Bishops' Committees on Doctrine and on Pro-Life Activities, we offer the following points to prevent misunderstanding and to help those involved in Catholic health care ministry more fully understand the church's teaching.
First, contrary to the "Rules for Interpretation" referred to by Hardt and Fr. O'Rourke,3 the CDF document was not issued in the form of a canonical decree. Nor is it merely a public policy statement motivated by the threat of legalized euthanasia in certain countries in Europe. It is an authoritative statement of moral truth, reaffirming a teaching by the Catholic Church's ordinary magisterium regarding how we are to exercise our freedom responsibly as children of God.
Second, not everything in the CDF's "Responses" applies solely to patients in a "vegetative state." For example, the CDF's first response states that "the administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life." Certainly this basic principle applies when patients have chronic but stable debilitating conditions that are less extreme than the "vegetative state." As the CDF "Commentary" notes, helpless patients with conditions such as quadriplegia, mental illness or Alzheimer's disease also must not be deprived of basic care and "abandoned to die" because their long-term care may burden others. The phrase "in principle" (which in this context means "as a general rule") is also important, because providing assisted food and fluids may cease to be obligatory in particular circumstances. The U.S. bishops asked whether such circumstances occur only when food and fluids "cannot be assimilated by the patient's body or cannot be administered to the patient without causing significant physical discomfort," and the CDF answered in the affirmative. The CDF "Commentary" notes that such circumstances will be "rare" and "exceptional" for a patient in a "vegetative state"; they may occur far more frequently for patients with progressively deteriorating or terminal conditions.
Also, the CDF "Commentary" notes the obligation to provide assisted feeding may not apply "in very remote places or in situations of extreme poverty" because we are not held to do something that is impossible in practical terms. But the CDF's statement about the general or presumptive obligation to provide food and fluids as a form of ordinary care clearly has broad application.
Third, in applying the church's longstanding moral tradition against euthanasia to the present question, the CDF is in full accord with that tradition. In 1980, the CDF (with the approval of Pope John Paul II) issued a "Declaration on Euthanasia" defining "euthanasia" as "an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated."4 In its more recent "Responses" and accompanying "Commentary," the CDF is stating that this issue is of particular concern regarding medically assisted food and fluids. Food and water are basic necessities of life, without which anyone (sick or healthy) would soon die. When they are withdrawn from a seriously disabled patient who needs help from others to obtain such basic care withdrawn not because the means themselves are useless or excessively burdensome, but because someone has judged that patient's continued life to be useless or burdensome the patient's death is the first result, and any other intended goals would seem to be met only through this death. The argument that in such cases the cause of death is merely the underlying condition (the inability to eat and swallow for oneself) is not valid, and is explicitly rejected by the CDF:
Patients in a "vegetative state" breathe spontaneously, digest food naturally, carry on other metabolic functions, and are in a stable situation. But they are not able to feed themselves. If they are not provided artificially with food and liquids, they will die, and the cause of their death will be neither an illness nor the "vegetative state" itself, but solely starvation and dehydration.5
Fourth, this brings us to the argument by Hardt and Fr. O'Rourke that the "significant financial hardships" of providing assisted food and fluids to patients in the "vegetative state" in the U.S. may justify withdrawing such care and letting the patient die.6 In reality, providing the complete range of long-term care for these helpless patients may indeed become very costly, and families should not be abandoned to carry these burdens alone. But providing food and fluids generally accounts for a very small fraction of this cost. If food and fluids are targeted for removal because this will lead to the patient's early death, thus saving the significant costs of other care, then it seems clear that the patient's death is being intended precisely as a means to saving these other costs. In other words, this would be a decision to practice euthanasia by omission.
Fifth, nothing in the CDF's "Responses" or in Pope John Paul II's address of 2004 provides a basis for withdrawing food and fluids based on a far broader category of "psychic burden." Hardt and Fr. O'Rourke say that some may "feel" the continued life of a patient in a "vegetative state" is a burden to others, or is not a benefit. This may be true, but such feelings do not justify euthanasia by omission or the deliberate withdrawal of basic care owed to patients because of their human dignity.
Sixth, regarding advance directives such as the "living will," Hardt and Fr. O'Rourke claim that under the Ethical and Religious Directives for Catholic Health Care Services (ERDs) people may continue to make advance decisions regarding their care (Directives 25 and 28).7 This is true as far as it goes. However, Directive 28 provides that "the free and informed health care decision of the person or the person's surrogate is to be followed so long as it does not contradict Catholic principles" (emphasis added). Moreover, Directive 24, not cited by Hardt and Fr. O'Rourke, also speaks of generally respecting patients' and surrogates' decisions, but adds:
The institution, however, will not honor an advance directive that is contrary to Catholic teaching. If the advance directive conflicts with Catholic teaching, an explanation should be provided as to why the directive cannot be honored.
The CDF's "Responses" provide clarifications as to what Catholic moral principles require of us on the provision of food and fluids, out of respect for the perduring human dignity of even the most severely cognitively disabled of our brothers and sisters.
On the relationship between the ERDs and the CDF's "Responses," the USCCB had this to say in its Q&A document:
Directive 58 already speaks of "a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration." The Address and the Responses clarify how this presumption applies to the patient in a "vegetative state" as to other patients, and provide further guidance as to how the Directives should be interpreted and implemented.8
We fully intend that the next edition of the ERDs will be amended to reflect this doctrinal clarification.
While we disagree with other claims by Hardt and Fr. O'Rourke, we believe these are the most important points in need of clarification. Certainly, when they say it is "questionable" whether the Catholic community will rise to the challenge of caring for the basic needs of patients in the "vegetative state," we hope their pessimism is unwarranted. It is precisely in caring for the poorest and most helpless of patients, those whose value and dignity are dismissed by others, that Catholic health care most clearly lives up to its mission and demonstrates the need for specifically Catholic health care providers in our secularized society. It is in meeting the moral challenge of caring for the most helpless that we will live up to our own God-given dignity.
- The U.S. Conference of Catholic Bishops news release of Sep. 14, 2007, on this development, with links to the CDF's "Responses" and "Commentary," and the USCCB's related Q&A, can be found at www.usccb.org/comm/archives/2007/07-143.shtml. Pope John Paul II's March 20, 2004, address can be found at www.vatican.va/holy_father/john_paul_ii/speeches/2004/ march/documents/hf_jp-ii_spe_20040320_congress-fiamc_en.html.
- John Hardt and Kevin O'Rourke, Nutrition and Hydration: The CDF Response, In Perspective. Health Progress, November-December 2007.
- Hardt and O'Rourke, 45.
- Congregation for the Doctrine of the Faith, "Declaration on Euthanasia," (May 5, 1980) www.vatican.va/roman_curia/congregations/cfaith/documents/ rc_con_cfaith_doc_19800505_euthanasia_en.html.
- Congregation for the Doctrine of the Faith, "Commentary." See note one above for link information.
- Hardt and O'Rourke, 46.
- U.S. Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, (Washington, D.C.) Fourth Edition, 2001, www.usccb.org/bishops/directives.shtml.
- See note one above.
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