Artificial nutrition, hydration: Assessing papal statement

By THOMAS A. SHANNON and JAMES J. WALTER

In addressing the international congress “Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas,” which was sponsored by the World Federation of Catholic Medical Associations and the Pontifical Academy for Life, Pope John Paul II argued, according to a March 22 statement from the Vatican Information Service, that the administration of artificial nutrition and hydration (ANH) through feeding tubes is “a natural means of preserving life, not a medical act.” At one point, the pontiff claimed that ANH for patients in a persistent vegetative state (PVS) is not a medical act (non un atto medico). Yet, later, he claims that their use must be considered ordinary and proportionate (ordinario e proporzionato), which seems to imply that this kind of intervention is indeed a type of treatment, though an ordinary and morally required one. Additionally, people in a persistent vegetative state will always remain human, maintain their dignity and have “the right to basic health care [nutrition, hydration, cleanliness, warmth].” Furthermore, according to the pope, 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.” Additionally, the pope states, “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 life of these patients.” Finally, the pope notes, “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.”

Ordinary or extraordinary

This analysis and the conclusions drawn from it appear to represent a major reversal of the moral tradition of the Catholic church in assessing whether a particular medical or other intervention is morally obligatory, particularly in the determination of whether this intervention is ordinary or extraordinary treatment. Additionally, the primary determinant of whether the intervention is morally ordinary or extraordinary is not how the intervention -- whether a medical therapy or some other kind of intervention -- is classified. Historically, the determinant has been the effect on the patient. Thus the fact that some intervention is considered a “natural means” (un mezzo naturale), as the pope suggests, does not determine the moral or obligatory status of the intervention. A few remarks are therefore in order.

First, the Catholic moral tradition determines whether an intervention is ordinary or extraordinary based on a proportionate-disproportionate means test, according to the 1980 Congregation for the Doctrine of the Faith’s “Declaration on Euthanasia.” In paragraph 4, the declaration says, “In any case, it will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree 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.” The declaration then gives four examples. The patient can choose to use the most advanced medical means available; such participation in research may also be a service to the rest of humanity. Second, the patient is permitted to stop interventions when the results fall short of expectations. Third, the refusal of a technique that is in use but carries a risk or is burdensome is not the equivalent of suicide. Finally, “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.”

The basic point here is that ordinary and extraordinary forms of treatment are not determined by classifying an intervention according to whether or not it is routinely used by physicians. This empirical definition of ordinary-extraordinary is not helpful in this context, and it is not what the Catholic tradition had in mind when the distinction was developed. Whether a medical intervention is morally ordinary has historically been determined by its effect on the patient or on those who have the responsibility to care for the patient. To argue that what is medically ordinary as determined by its routine usage by physicians is also morally ordinary equivocates on the term “ordinary” and misrepresents the core of the medical ethical tradition of the Catholic church, a tradition in place since at least the 16th century. Early moral theologians, for example, taught that cloistered nuns who might be embarrassed by a medical examination were under no obligation to have such an examination. It was an extraordinary procedure because of the burden it placed on them.

The dignity of the patient

Second, to determine that an intervention is morally extraordinary, and therefore should either not be initiated or withdrawn, is not to deny the personhood of the patient or to devalue the person’s dignity. Likewise, such forgoing or withdrawal does not necessarily imply that the intention of the physician or family is to end the life of the patient. It might simply be to recognize that either the proposed intervention is not useful in helping to restore the patient to health or that the patient is dying or in a condition that will lead to death and that the moral obligation is to accompany this person on their final journey. The intention might also be to respect the patient’s considered wishes when competent not to have such interventions put in place when the patient falls into a persistent vegetative state. Mandating useless or unwanted interventions might well be the violation of the person’s dignity, and therefore we should be deeply worried about this in a clinical setting.

Third, when people begin dying, they frequently stop eating and drinking. This is a part of the dying process and interfering with it may in fact interfere with this process and actually harm the patient. Such interventions are morally counter-indicated as both harmful and extraordinary. A person in a persistent vegetative state, assuming a correct diagnosis (and such a diagnosis will and should take some time), is incapable of orally eating or drinking by his or her self. To the best medical knowledge, when properly diagnosed, such a condition is irreversible. It cannot be cured. The damage to the brain is so severe that nothing can be done to reverse that condition, and the patient will not return to any level of sapient or sentient existence. There is a whole medical literature about the medical condition of such patients that is most relevant for the discussion of this question.

Harmful side effects

What can be done is to intervene with artificial nutrition and hydration to maintain the physiological process and to prevent death. All the artificial feeding does is maintain the biological processes of the person. It does not directly contribute to the person’s recovery or maintain them in a stable condition as part of an ongoing therapeutic process. Artificial nutrition and hydration cannot make such contributions because recovery is not an option for a person in a persistent vegetative state or for one in the dying process. Such interventions can in some instances harm the person because of the possibility of known harmful side effects, such as infections at the site of the insertion of the tube, nausea, vomiting and the possibility of the vomit choking the patient, abdominal swelling, cramping and perhaps diarrhea. Some patients occasionally tear them out. And whether this is done consciously or unconsciously, the tube needs to be reinserted, and this exposes the patient to more risks. There is a well-established medical literature on the harms and burdens associated with tube feeding. It might be helpful to consult such literature before claiming that such interventions are not a medical treatment.

There has been a strong moral argument, grounded in the history of Catholic medical ethics, that the use of feeding tubes for nutrition and hydration can be judged in some circumstances as extraordinary, and thus not morally obligatory. This argument has been based on the view that no intervention in the abstract can be judged either ordinary or extraordinary. Such a prudential judgment always requires knowledge of a specific patient and his/her own evaluation of the proposed intervention. Not only the means (proposed intervention) but the ends toward which the intervention is aimed are important in the moral analysis. In the concrete medical setting, it would be improper to say that there are never any burdens connected to feeding tubes. There are physical burdens and harms that can be associated with artificial nutrition and hydration. The treatments can be expensive, especially the placing of the feeding tube by medical personnel. According to the Congregation for the Doctrine of the Faith’s declaration, one may refuse an intervention from a desire “not to impose excessive expense on the family or the community.” This statement recognizes that there is no moral obligation to spend either one’s own or the community’s money on treatments that do not bring benefit to patient’s overall condition or that might be judged burdensome or psychologically repulsive.

Fourth, this address by John Paul II seems to represent to us an elevation of biological or physical life to an almost absolute value. The statement comes close to saying that life must be preserved for its own sake. Yet in his encyclical Evangelium Vitae, he clearly states, “Certainly the life of the body in its earthly state is not an absolute good for the believer, especially as he may be asked to give up his life for a greater good.”

The Catholic medical ethics tradition has not required that a person actually be dying before interventions could be terminated. However, the pope seems to imply in this statement and in Evangelium Vitae that death must be imminent. In Evangelium Vitae, at article 65, he states, “In such situations, when death is clearly imminent and inevitable, one can in conscience refuse forms of treatment that would only secure a precarious and burdensome prolongation of life ” (our emphasis). In the broader Catholic tradition, which includes the Vatican’s “Declaration on Euthanasia,” medical interventions can be removed when they are defined as morally extraordinary because of their burdens or because they are no longer useful in securing a medical benefit for the patient. If such interventions can no longer be forgone or withdrawn, then we are in severe danger of making biological life an absolute value and an end in itself. Human life, of course, has not been so evaluated in the Catholic medial ethics tradition or in the Catholic theological tradition.

Preventing euthanasia

Finally, though this papal statement seeks to prevent the practice of euthanasia, whether by commission or by omission, this way of stating the matter may in fact have the reverse outcome. If people are told that removing useless and burdensome interventions is morally prohibited and that they are morally obligated to provide such interventions right up to the point of natural death, many people may conclude that this moral advice contradicts their deepest moral instincts and will simply ignore it. And if the most pastorally sensitive part of Catholic medical ethics -- the recognition that once an intervention is judged either useless or burdensome, it can be rejected -- is jettisoned, many people will conclude, rightly or wrongly, that one might just as well go directly to euthanasia since there is no relevant moral analysis for considering the appropriate medical and moral treatment of the sick or the permanently unconscious.

Many other important questions remain. Why is this statement not framed within a broader theological reflection on the meaning of life? One thinks of Pope Pius XII’s allocution on “The Prolongation of Life” in 1957 that placed these decisions about forgoing and withdrawing medical interventions in the theological context of the spiritual ends of life. He stated, “Life, health, all temporal activities are in fact subordinated to spiritual ends.” Furthermore, what is the level of magisterial authority with which this statement is proclaimed? Is it an application of the pope’s positions enunciated in Evangelium Vitae on end-of-life questions? Does this statement apply only to patients in a persistent vegetative state, or does it also extend to other categories of patients who need permanent feeding tubes inserted but are not in a persistent vegetative state? If the traditional distinction between ordinary and extraordinary means applies to other categories of patients on this issue, then on what grounds do we argue that it is always required of patients in a persistent vegetative state? Surely, the reason cannot be that these patients might not have made their wishes known ahead of time and thus are vulnerable to others’ interpretations of their informed judgment. We know that many Catholics have already signed “living wills” while competent and in good faith, saying that they do not want such interventions used if they fall into a persistent vegetative state. Therefore, families that refer to these documents are attempting to be faithful to the wishes of the patient and are not attempting to end the life of the patient because the patient is a burden on them. Many more questions remain, but we are left with a sense that the pope’s rightful purpose to protect patients in a persistent vegetative state and to curb the movement toward euthanasia has not achieved its goal in this statement.

Thomas A. Shannon is professor of religion and social ethics at Worcester Polytechnic Institute, Mass., author of many books on bioethics and social ethics, and a longtime member of the Catholic Theological Society of America.

James J. Walter is Austin & Ann O’Malley Professor of bioethics and director of The Bioethics Institute at Loyola Marymount University and an author of many articles and books on medical ethics and biotechnology.

Shannon and Walter recently co-authored The New Genetic Medicine: Theological and Ethical Reflections (Sheed & Ward).

National Catholic Reporter, April 16, 2004