Allowing to die II.

Speaking last month to an international congress of physicians and ethicists in Rome, Pope John Paul II declared that the "administration of food and water, even when provided by artificial means, always represents a natural means of preserving life, not a medical act." He added that providing hydration and nutrition is "in principle, ordinary and proportionate, and as such, morally obligatory." The pope was speaking about patients in a persistent vegetative state (PVS) who, because of severe brain damage, are not conscious and cannot ingest food or water naturally.

John Paul has been a vigilant defender of the dignity of human life in all its stages, and he was no doubt attempting to strengthen safeguards against euthanasia and any rush to abandon PVS patients. It is unlikely, however, that his remarks will serve that purpose. Unfortunately, the pope's statement promises to make decisions for families caring for PVS patients even more difficult. It also appears to turn centuries of Catholic moral teaching on its head. Strangely, the pope's statement seems at odds with his own earlier writing, and comes curiously close to endorsing the notion of vitalism, a philosophy that he has firmly rejected in the past. In Evangelium vitae, John Paul wrote that "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 the greater good." That statement relied upon earlier papal documents, including Pope Pius XII's balanced and influential 1957 address, "The Prolongation of Life."

The treatment of PVS patients has been the subject of an increasingly politicized debate about end-of-life care. Last October in the Terri Schiavo case (see Commonweal, "Allowing to Die," November 7, 2003), the Florida state legislature approved a bill sought by Governor Jeb Bush to order the reinsertion of Schiavo's feeding tube at the behest of her parents, who were fighting her husband who wished to remove it. The case, in which the state became entangled in the most personal medical decision making, did little to clarify the moral issues surrounding the treatment of PVS patients. While prolife groups rallied to the defense of Schiavo's parents, Florida's bishops cautiously stated that removing food and hydration from a PVS patient was permitted in certain cases. (Schiavo has been in this condition for thirteen years.)

Disagreement among Catholics about the moral obligation to keep PVS patients alive is not new. In 1990, Texas bishops wrote that removing a feeding tube was acceptable in certain circumstances. In 1999, that conclusion was challenged by bishops in Pennsylvania, who argued that feeding tubes for PVS patients are "within the realm of ordinary means."

John Paul II and his advisers should not try to end this useful debate by papal fiat. The pope's remarks will not by themselves resolve a question that has perplexed theologians, ethicists, bishops, and doctors for decades. On the contrary, the pope's commitment to prolonging life "until it is seen to have attained its proper finality" may only cloud the moral debate. Who should determine when a dying or brain-dead person's life has "attained its proper finality"?

The pope's statement has already generated concern in the ethics and medical communities. How, some wonder, are doctors to deal with patients who request not to be connected to a feeding tube? What about families who have been caring for relatives in PVS for years, even decades? It seems obtuse to tell them that discontinuing artificial nourishment is, in the pope's words, "euthanasia by omission." Just as worrisome, will the families of some patients who could benefit from a feeding tube now refuse the procedure out of fear that should the treatment prove futile, the patient might never be disconnected?

The Catholic moral tradition has long recognized that it is permissible, under certain circumstances, to withdraw artificial nourishment from patients in a vegetative state. The late Richard A. McCormick, SJ, wrote compellingly about the dangers of confusing what one can do for a patient with what one ought to do. At the conference in Rome preceding the pope's statement, Salvino Leone, a professor of moral theology, reminded his audience of the traditional Catholic teaching that distinguishes between "giving death" and "letting die." In light of the pope's subsequent remarks, the conference itself would appear to be another example of the growing disconnect between bishops and theologians on matters of faith and morals.

The pope seems aware of what an absolute commitment to the prolongation of biological life might involve. In his speech, he called for "awakening centers," where PVS patients would receive extended care. Openness to the miraculous is admirable, but traditional Catholic moral teaching has rightly never relied on the expectation of miraculous cures, nor should it now.

Deciding when to remove a loved one's feeding tube is among the most difficult decisions a family is likely to face. The ongoing debate about the issue--in religious, medical, and legal circles--is entirely necessary and must not be cut short. For generations, Catholic moral teaching has attempted to balance the need to safeguard life with the need to allow for families and doctors to discontinue futile and burdensome treatment. Sound medical ethics tells us that the ultimate purpose of any medical treatment--including artificial hydration and nutrition--is to help the patient recover. If treatment fails to achieve this, at some point it must be judged unsuccessful and, when appropriate, abandoned. When a feeding tube is removed in such cases, the cause of death is rightly understood to be the underlying condition that made it impossible for the patient to swallow food and water in the first place. It is this kind of rigorous yet compassionate thinking that has earned Catholic moral principles an honored place in the public debate about end-of-life care. That Catholic voice must not be silenced or diminished.