Catholic teaching stresses the moral obligation of sustaining all human life, provided that the benefits of treatment outweigh the burdens.
How extensively this principle applies to patients with a low level of brain activity — and what Pope John Paul II has to say about it — has been the crux of considerable controversy in recent months.
This debate arose from the pope’s March 20 statement on the administration of nutrition and hydration to patients in a persistent vegetative state, a medical condition marked by low levels of neurological functioning.
According to the pope, the delivery of food and water, even by such “artificial means” as a feeding tube, “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.”
The pontiff said this obligation applies even to patients who have been in a persistent vegetative state for more than a year. Discontinuation of nutrition and hydration, in this instance, “ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission,” he said.
Pope John Paul issued his allocution, or teaching statement, on the final day of the four-day Vatican conference “Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas.” For a full text of the March 20 statement, go to the “Speeches” link for Pope John Paul II at www.vatican.va. The conference was attended by more than 350 theologians, doctors and other life-issues experts from around the world, including Jann Armantrout, life-issues coordinator for the Diocese of Rochester.
The Rochester Diocese has prepared a statement about the pope’s comments, as well as a list of questions and answers on the topic. Both documents can be found under “Top Stories” in this Web site’s Local News section.
Many observers have interpreted the pope’s message as putting a new spin on existing church teaching. For instance, a statement by Father Michael D. Place, president of the Catholic Health Association of the United States, noted that the pope’s allocution “reminds us of our responsibility never to abandon the sick or dying. That being said, the guidance contained in his remarks has significant ethical, legal, clinical, and pastoral implications that must be carefully considered. This will require dialogue among sponsors, bishops, and providers.”
The subject of caring for people with low levels of neurological functioning is addressed in the U.S. bishops’ 1994 Ethical and Religious Directives for Catholic Health Services which states, “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” (58).
In addition, the bishops emphasized a moral obligation to use proportionate means of preserving life. According to the directives, proportionality is determined by whether the treatments “offer a reasonable hope of benefit” and whether they “entail an excessive burden or impose excessive expense on the family or community” (56, 57).
Further, the Catechism of the Catholic Church states: “Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of ‘over-zealous’ treatment. Here one does not will to cause death; one’s inability to impede it is merely accepted. The decisions 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” (2278).
Sister of St. Joseph Patricia Schoelles, a theological ethicist and president of St. Bernard’s School of Theology and Ministry in Pittsford, said the teachings fall between two extremes.
“We want to avoid the extreme of directly killing patients because they’re sick, suffering, limited. At the same time, there’s a group called ‘absolute vitalists’ who say you must retain the biological organism no matter what,” she said. “Catholics have never been absolute vitalists. We don’t want to keep people alive and prolong the dying, but we don’t want to kill people just because they’re sick.”
Sister Schoelles added that the pope’s March 20 statement “is in the context of this document (the ethical and religious directives), which is very sound. He doesn’t make pronouncements outside of it.”
“I think it’s maybe a clarification and, in some ways, an expansion,” Armantrout remarked, adding that the pope was emphasizing the possibility, however small, of recovery for persons in persistent vegetative states. “Some of them do recover after months, years,” she said.
Armantrout added that the pope’s presentation was consistent with the tenor of the Vatican symposium. “It was a real reflection of the 90 presentations that were given during the course of the conference,” she said. “There was a great deal of unanimity and solidarity.”
His words could be influential in such cases as the well-publicized struggle over the treatment of Terri Schiavo, a Florida woman whose parents continue legal battles to maintain the feeding tube that has kept her alive since 1990. Schiavo’s husband has sought to have the tube removed, saying his wife would not have wanted to be kept alive artificially.
Father Place indicated that the pope’s statement also could be expanded to include “practical implications for those patients who are not in a vegetative state.” And some critics charge that the pope’s statement of “moral obligation” ignores the need to weigh a treatment’s burden against the benefit it offers.
But Sister Schoelles said the pope “wasn’t giving us a mandate or a rule that governs every person’s care,” noting that his comments actually focus on a very small percentage of the population.
“The secular press is saying, ‘The pope said nobody can ever die.’ But we’re not talking about people in the active process of dying,” added Armantrout. “We’re talking about people with profound disabilities.”
Even so, she said reporting about Pope John Paul’s statement has led some people to worry that their advance directives (specific instructions outlining what types of medical treatment a person wants if he or she becomes incapacitated) and health-care proxies (which designate a specific individual to make medical decisions on behalf of someone who becomes incapacitated) are in conflict with church teachings.
“I’ve got a few calls from elderly people (asking), ‘Did I do the wrong thing by not putting Joe on dialysis?'” Armantrout said.
Yet Sister Schoelles said she does not see “any obligation of the people whose proxies have been faithfully completed to change them.”
Sister Schoelles also doesn’t foresee a revision of the U.S. bishops’ ethical and religious directives, noting that they were 50 years in the making. Armantrout added that Pope John Paul’s March 20 statement “was issued in principle — as an allocution, not an infallible statement.”
Nonetheless, both agreed that discussion will be needed to link the pope’s statement with the current directives. For instance, Sister Schoelles said, it may be difficult to untangle the potential contradiction entailed in the pope’s defining such devices as a feeding tube as natural means, not a medical act.
Armantrout emphasized that issues addressed by the pope “raise questions for each person that all mankind must deal with. It is not just a Catholic question.”
Sister Schoelles, meanwhile, suggested that answers to the following questions can shed light on the issue:
- How is death brought about?
- Why are we allowing a person to die?
- By whom are these decisions being made?
- At what cost?
In regard to who makes the decisions, Armantrout voiced concern about medical and political forces in society that favor euthanasia, physician-assisted suicide and other actions opposed to Catholic teaching. She said a dangerous precedent would be set by relaxing moral standards on treatment for people in persistent vegetative states, where administering of life-sustaining treatment is based on the quality of life. Such a relaxation eventually could lead to use of quality-of-life criteria in making treatment decisions for people who are sick but not dying, those with disabilities, and the elderly.
“Are we going to start saying, ‘It’s really time for Mabel to go; what’s she really contributing?'” Armantrout asked.
The pope addressed that very point March 20, saying, “Considerations about the ‘quality of life,’ often actually dictated by psychological, social and economic pressures, cannot take precedence over general principles … the value of a man’s life cannot be made subordinate to any judgment of its quality expressed by other men.”