INTERIM PASTORAL STATEMENT ON ARTIFICIAL NUTRITION AND HYDRATION

Bishop Rene H. Gracida

A Dissent From The “Interim Pastoral Statement On Artificial Nutrition And Hydration” Issued By The Texas Conference Of Catholic Health Facilities And Some Of The Bishops Of Texas

Recently the Texas Catholic Conference in Austin released the final text of the document approved by the Texas Catholic Conference of Health Facilities and sixteen of the twenty-one Bishops of Texas. I had declined to sign the document because I consider it to be seriously flawed.

It seems to me that the document gives a higher priority to efforts to relieve the burden caused by a serious illness rather than efforts to protect the sick person’s right to life. The document deals with the withdrawal of nutrition and hydration from a seriously ill patient.

This whole matter is one which is being debated by the legal and medical professions as well as by theologians and ethicists. The Holy See has this whole controversial area of morality under review and will undoubtedly issue a major declaration on the subject sometime in the next year or two.

In the meantime, I would have preferred to see my fellow Bishops of Texas issue a document which would have made a stronger statement in support of the sick person’s right to receive food and drink as the basic necessities of life.

My specific objections to the text of the statement which was recently made public, are:

1. In the title and throughout the text, the phrase “artificial nutrition and hydration” is used. This is inaccurate: the food and water used are not artificial. It is medically appropriate to speak of “artificially assisted nutrition and hydration.” It is the mode of assistance that is artificial.

2. Under “Basic Moral Principles” the Declaration on Euthanasia is used selectively. As the title of that document indicates, one must begin with a rejection of euthanasia—defined by the Declaration as “an action or an order that all suffering may in this way be eliminated.”

Only “after” one has established that an omission of care or treatment is not directly intended to bring about death should one turn to the complex task of assessing benefits and burdens. The question of intention is central here: If the removal of a life-sustaining procedure is intended to avoid an unreasonable burden of the procedure, so that a quicker death is only an unintended side-effect of the decision, it is not a case of euthanasia.

3. Also not treated here is the question whether artificially assisted feeding may be classified as “normal care” rather than “treatment.” The “Declaration” says normal care must be provided even when one has removed “forms of treatment that would only secure a precarious and burdensome prolongation of life” for an imminently dying patient.

Whether tube feeding may constitute “normal care” is not currently resolved by the magisterium; three non-magisterial bodies (Pontifical Council Cor Unum, editorial board of La Civilta Cattolica, and a working group of the Pontifical Academy of Sciences) have issued statements answering the question in the affirmative. If tube feeding has some aspects of “normal care,” this would strengthen the presumption in favor of providing it in most cases.

4. The inclusion of burdens on “others—family, care provider, or community”—is more broadly stated than in existing Church documents. The Declaration on Euthanasia speaks of the “patient himself” validly making a self-sacrificing decision not to burden other: when those “others” are the agents making the decision, other factors (including the Golden Rule) come into play.

“All” long-term care for seriously impaired patients is a “burden” on the community, but it may be a burden that has to be willingly shouldered: “The respect, the dedication, the time and means required for the care of handicapped persons, even of those whose mental faculties are gravely affected, is the price that a society should generously pay in order to remain truly human” (Document of the Holy See for the International Year of Disabled Persons, 1981.)

5. The phrase about “investment in medical technology and personnel disproportionate to the expected results” is taken from a paragraph in the Declaration on Euthanasia that concerns “the most advanced medical techniques,” especially those “at the experimental stage.” This document applies the phrases to life-supporting means generally.

6. I know of no Church document that says treatment is disproportionate when it involves “inequitable resource allocation.” This could be a broad loophole for communities saying that severely impaired persons are not worth the money. The phrase should be clarified or deleted.

7. The restrictive statement that “maintenance of life” is a benefit only when it involves reasonable hop of recovery” could ground discriminatory withholding of life preserving means from people with incurable disabilities.

It vitiates the principle that everyone has the same basic “right to life” regardless of age or condition, which in Catholic social teaching means that every person has the same basic right to the necessities that sustain life. Life is “always a good.” How can it be a good without being a benefit?

8. The equation between “foregoing” and “withdrawing” is an oversimplification. What of cases where initiation of tube feeding entails the transient risks and burdens of minor surgery under general or local anesthesia, but its maintenance does not involve these burdens? Must this change in the burden/benefit calculus be ignored?

9. The claim that the NCCB Pro-Life Committee came to the “same conclusion” is overstated. The Committee’s chief message was rejection of any efforts at “intentionally hastening the deaths of vulnerable patients by starvation or dehydration”; as was said in point #2 above, the text under consideration does not have this focus.

Also, the Pro-Life Committee document clearly supports tube feeding that can “effectively preserve ‘life’ without involving too grave a burden”; the present draft, as noted above, judges effectiveness in terms of preserving “life with reasonable hope of recovery,” which is a different standard.

10. The question of “cause of death” is a major open question in the current debate. This text overstates the importance of that question, because traditional moral teaching puts great weight on “intention.”

It also understates the causal role of an omission of nutrition and hydration in hastening death, in cases where a patient could have survived in a medically stable condition for years with continued feeding. The phrase “proximate physical means” is obscure, and should have been replaced by “proximate physical cause of death.” One can recognize that the omission is the proximate cause leading to death, while reaffirming that the hastening of death is “praeter intentionem” in some cases.

11. The claim that all these decisions are made “by the patients themselves and by no one else” is not supported in the Church documents. The Declaration says “account will have to be taken of the ‘reasonable’ wishes of the wishes of the patient ‘and the patient’s family,’ as also of ‘the advice of the doctors’ who are specially competent in the matter.”

In cases of doubt “it pertains to the conscience either of the sick person, ‘or’ of the doctors, to decide, in the light of moral obligations and of the various aspects of the case.” In the Declaration a major “moral obligation” binding on “all” decision makers is the rejection of euthanasia by action or omission. Theses qualifications are all absent from (even explicitly rejected by) the document.

12. To say the “morally appropriate” withdrawal of tubal feeding is not “abandoning the person” is a truism. It is equally true to say: “The morally inappropriate withdrawal of tube feeding ‘is’ abandonment of the person.”

This leaves us nowhere, because the text gives no guidelines on when the burdens of artificially assisted feeding are grave enough to render this means optional (except for the overboard standard cited above that whatever the patient says is right).

13. The statement that the patient should not be impeded from “taking the final step” has an ominous sound to it; it might give the impression that hastening death can be directly intended. A phrase like “accepting the inevitability of death ” would have been better.

14. The phrase “threat ‘of’ life” on page 5, line 19 is, I hope, a misprint for “threat ‘to’ life.” The presumption seems to be that death from a life-threatening condition is the “normal consequence” that should occur, and one needs a special reason to “impede” this “normal” state of affairs.

The burden of proof should go the other way: We have a “prima facie” obligation to save someone’s life unless there is a special reason (e.g., ineffectiveness, grave burdensomeness) not to do so. One senses here a very passive model for human action in the world in cases of preventable death—one that does not comport well with the stated “presumption” in favor of averting death.

15. The document as a whole should have distinguished more clearly between two classes of patients: Those who are dying soon no matter what we do for them (e.g., terminal cancer patient), and those who are medically stable and are “not” dying if provided with continued nutrients and fluids.

A much more permissive standard is possible for the former class of patients, for whom continued feeding may become strictly useless in prolonging life. A strong presumption could be established in favor of life-sustaining feeding for the latter class, rebuttable in cases of excessive burden.

A strong presumption here is especially important because, in some celebrated cases, tube feeding has apparently been withdrawn from the latter class of patients precisely because they are “not” dying and someone wants death to occur (see ACLU brief in the Hector Rodas case, cautionary statements by ethicist Daniel Callahan, and concurring opinion by Judge Lynn Compton in the Elizabeth Bouvia case).

This statement was published in the May 25, 1990 edition of the Corpus Christi “Diocesan Press.”

Here follows the teaching of Pope John Paul II, on the same issue:

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

Distinguished Ladies and Gentlemen,

1. I cordially greet all of you who took part in the International Congress: “Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas”. I wish to extend a special greeting to Bishop Elio Sgreccia, Vice-President of the Pontifical Academy for Life, and to Prof. Gian Luigi Gigli, President of the International Federation of Catholic Medical Associations and selfless champion of the fundamental value of life, who has kindly expressed your shared feelings.

This important Congress, organized jointly by the Pontifical Academy for Life and the International Federation of Catholic Medical Associations, is dealing with a very significant issue: the clinical condition called the “vegetative state”. The complex scientific, ethical, social and pastoral implications of such a condition require in-depth reflections and a fruitful interdisciplinary dialogue, as evidenced by the intense and carefully structured programme of your work sessions.

2. With deep esteem and sincere hope, the Church encourages the efforts of men and women of science who, sometimes at great sacrifice, daily dedicate their task of study and research to the improvement of the diagnostic, therapeutic, prognostic and rehabilitative possibilities confronting those patients who rely completely on those who care for and assist them. The person in a vegetative state, in fact, shows no evident sign of self-awareness or of awareness of the environment, and seems unable to interact with others or to react to specific stimuli.

Scientists and researchers realize that one must, first of all, arrive at a correct diagnosis, which usually requires prolonged and careful observation in specialized centres, given also the high number of diagnostic errors reported in the literature. Moreover, not a few of these persons, with appropriate treatment and with specific rehabilitation programmes, have been able to emerge from a vegetative state. On the contrary, many others unfortunately remain prisoners of their condition even for long stretches of time and without needing technological support.

In particular, the term permanent vegetative state has been coined to indicate the condition of those patients whose “vegetative state” continues for over a year. Actually, there is no different diagnosis that corresponds to such a definition, but only a conventional prognostic judgment, relative to the fact that the recovery of patients, statistically speaking, is ever more difficult as the condition of vegetative state is prolonged in time.

However, we must neither forget nor underestimate that there are well-documented cases of at least partial recovery even after many years; we can thus state that medical science, up until now, is still unable to predict with certainty who among patients in this condition will recover and who will not.

3. Faced with patients in similar clinical conditions, there are some who cast doubt on the persistence of the “human quality” itself, almost as if the adjective “vegetative” (whose use is now solidly established), which symbolically describes a clinical state, could or should be instead applied to the sick as such, actually demeaning their value and personal dignity. In this sense, it must be noted that this term, even when confined to the clinical context, is certainly not the most felicitous when applied to human beings.

In opposition to such trends of thought, I feel the duty to reaffirm strongly that the intrinsic value and personal dignity of every human being do not change, no matter what the concrete circumstances of his or her life. 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”.

Even our brothers and sisters who find themselves in the clinical condition of a “vegetative state” retain their human dignity in all its fullness. The loving gaze of God the Father continues to fall upon them, acknowledging them as his sons and daughters, especially in need of help.

4. Medical doctors and health-care personnel, society and the Church have moral duties toward these persons from which they cannot exempt themselves without lessening the demands both of professional ethics and human and Christian solidarity.

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 eventual recovery.

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.

The obligation to provide the “normal care due to the sick in such cases” (Congregation for the Doctrine of the Faith, Iura et Bona, p. IV) includes, in fact, the use of nutrition and hydration (cf. Pontifical Council “Cor Unum”, Dans le Cadre, 2, 4, 4; Pontifical Council for Pastoral Assistance to Health Care Workers, Charter of Health Care Workers, n. 120). The evaluation of probabilities, founded on 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.

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).

Besides, the moral principle is well known, according to which even the simple doubt of being in the presence of a living person already imposes the obligation of full respect and of abstaining from any act that aims at anticipating the person’s death.

5. Considerations about the “quality of life”, often actually dictated by psychological, social and economic pressures, cannot take precedence over general principles.

First of all, no evaluation of costs can outweigh the value of the fundamental good which we are trying to protect, that of human life. Moreover, to admit that decisions regarding man’s life can be based on the external acknowledgment of its quality, is the same as acknowledging that increasing and decreasing levels of quality of life, and therefore of human dignity, can be attributed from an external perspective to any subject, thus introducing into social relations a discriminatory and eugenic principle.

Moreover, it is not possible to rule out a priori that the withdrawal of nutrition and hydration, as reported by authoritative studies, is the source of considerable suffering for the sick person, even if we can see only the reactions at the level of the autonomic nervous system or of gestures. Modern clinical neurophysiology and neuro-imaging techniques, in fact, seem to point to the lasting quality in these patients of elementary forms of communication and analysis of stimuli.

6. However, it is not enough to reaffirm the general principle according to which the value of a man’s life cannot be made subordinate to any judgment of its quality expressed by other men; it is necessary to promote the taking of positive actions as a stand against pressures to withdraw hydration and nutrition as a way to put an end to the lives of these patients.

It is necessary, above all, to support those families who have had one of their loved ones struck down by this terrible clinical condition. They cannot be left alone with their heavy human, psychological and financial burden. Although the care for these patients is not, in general, particularly costly, society must allot sufficient resources for the care of this sort of frailty, by way of bringing about appropriate, concrete initiatives such as, for example, the creation of a network of awakening centres with specialized treatment and rehabilitation programmes; financial support and home assistance for families when patients are moved back home at the end of intensive rehabilitation programmes; the establishment of facilities which can accommodate those cases in which there is no family able to deal with the problem or to provide “breaks” for those families who are at risk of psychological and moral burn-out.

Proper care for these patients and their families should, moreover, include the presence and the witness of a medical doctor and an entire team, who are asked to help the family understand that they are there as allies who are in this struggle with them. The participation of volunteers represents a basic support to enable the family to break out of its isolation and to help it to realize that it is a precious and not a forsaken part of the social fabric.

In these situations, then, spiritual counselling and pastoral aid are particularly important as help for recovering the deepest meaning of an apparently desperate condition.

7. Distinguished Ladies and Gentlemen, in conclusion I exhort you, as men and women of science responsible for the dignity of the medical profession, to guard jealously the principle according to which the true task of medicine is “to cure if possible, always to care”.

As a pledge and support of this, your authentic humanitarian mission to give comfort and support to your suffering brothers and sisters, I remind you of the words of Jesus: “Amen, I say to you, whatever you did for one of these least brothers of mine, you did for me” (Mt 25: 40).

In this light, I invoke upon you the assistance of him, whom a meaningful saying of the Church Fathers describes as Christus medicus, and in entrusting your work to the protection of Mary, Consoler of the sick and Comforter of the dying, I lovingly bestow on all of you a special Apostolic Blessing.