The pope on PVS: Does JP II's statement make the grade?

A recent address by Pope John Paul II regarding the care of patients in a persistent vegetative state (PVS) has left many people--Catholics and others--scratching their heads. If the withdrawal of tube feeding or artificially administered hydration can be the equivalent of "euthanasia by omission," do we all need to rethink the decisions we have made in our advance directives and living wills? What immediate impact will this statement have on Catholic hospitals, for both Catholic and non-Catholic patients? Part of the difficulty in determining the weight and moral authority of the statement is that it comes from John Paul II himself, and it can be hard to separate the message from the messenger. Notwithstanding the authority of the messenger, the message deserves examination on its own terms. How might we read this text if it were, say, a thesis proposal submitted to an interdisciplinary committee for review at a Catholic university? Here is one possibility.

Dear Student:

We have read your proposal with great interest, as it addresses a topic about which there is much public debate. The ongoing case of Terri Schiavo in Florida is just one example.

In brief, you propose to show there is a moral obligation to maintain nutrition and hydration, "even artificially administered," for the PVS patient, saying that doing so is "necessarily ordinary and proportionate." You affirm that this is "not a medical act," but a "natural means of preserving life." In short, you say it is required whenever it works to maintain life.

While we are pleased to accept your proposal, we would like to bring up some issues to which you will want to pay particular attention as you continue your work. Our brief comments below will refer only to the 1980 Declaration on Euthanasia, the most authoritative statement by the church to date on the topic; the 1995 Pontifical Council's Charter of Health-Care Workers; and some older traditional references that represent the long-held moral tradition on this subject. Other sources will, of course, also need to be explored as you continue your work.

First, you summarize the clinical reality of PVS by stating that PVS is not a diagnosis, but "only a conventional prognostic judgment." You will want to be a little more precise here. In fact, PVS refers to a medical condition, defined by specific clinical indications that make it possible to distinguish a person in PVS from someone who is temporarily unconscious or in another form of coma. PVS includes periods of arousal and the return of sleep-and-wake cycles, when the patient seems "awake" but unfortunately is never aware. You state the person "seems unable to interact with others." In fact, what is misleading about PVS is that the opposite is true: although they remain unconscious and unaware, PVS patients may appear to be interacting. You then go on to suggest the possibility that PVS patients may recover from their condition. This possibility is a key part of your argument that we must not forgo nutritional support.

Your proposal, as now written, might be taken to suggest that a person's diagnosis--which is distinct from his or her medical condition and prognosis--is the key in deciding whether to continue or to forgo nutrition/hydration. More specifically, the person would seem to need to have a diagnosis of a terminal disease. Since a person in PVS is not, it would seem, terminally ill, administering nutrition/hydration would be considered "ordinary and proportionate," and forgoing it would constitute "euthanasia by omission." But an emphasis on diagnosis in making these decisions will be difficult for you to argue, for the Declaration states that we must consider "the results that can be expected taking into account the state of the sick person." In other words, the patient's prognosis and medical condition. In the 1950s, the moralist Gerald Kelly, SJ, concluded that forgoing nutrition/hydration was permissible when a patient was in a condition described at the time as a terminal coma: a condition from which he or she was unlikely to recover. Clinically speaking, patients in PVS today can be said to be in terminal comas. (Kelly is particularly important in this discussion since he played a significant role in developing the concepts of "ordinary" and "proportionate" care.) Another highly regarded traditional source of that time, Charles McFadden, noted that it would be a great hardship to be sustained indefinitely by artificially administered nutrition/hydration. You will need to frame your argument in light of these traditional understandings of the role of condition and prognosis.

Whatever the role of prognosis in decision making, you are clear that the lack of certainty for prognosis is important to your conclusion. It is true to some extent that science "is unable to predict with certainty who among patients in this condition will recover and who will not." But this need not lead to the conclusion that one may never forgo artificially administered nutrition/hydration. In your final work, you will need to distinguish between "clinical certainty," which may not exist in a particular case, and what Aquinas described as "moral certainty," which up to now most writers on this topic have held does exist in most PVS cases. You seem to suggest that if there is doubt regarding the prognosis, the ethical thing to do is to take the safest approach: care for the person as if he or she may recover. This approach has traditionally been called tutiorism. You will also need to engage fully that part of the ethical tradition that speaks of moral certainty in the face of prognostic uncertainty. That is, if there is legitimate clinical doubt that a person in PVS will recover, or if it is unreasonable to expect that the person will recover, it is ethical to make decisions with "moral certainty" that the person will probably not recover--what the tradition has called probabilism. Although in theory recovery is possible, we know that someone with the medical condition of PVS has a very poor prognosis. Recovery is clinically very rare, particularly after three months for nontraumatic injury, such as drug use, and after one year for traumatic injury, such as a car accident. Your final project will therefore need to include a thorough analysis of the work of Aquinas and Alphonsus Liguori in this regard. Other sources that have lent support to this approach are Pius XII's 1957 affirmation that life, health, and all temporal activities are subordinate to spiritual ends; and the Declaration's own affirmation that a person's "moral resources," his or her ability to cope with illness and its treatment, must be considered as part of the moral analysis. Kelly maintained that the clinical certainty should be "reasonable," not absolute, in determining what constitutes "ordinary care." One also thinks of Pope John Paul II's 1992 discussion of "therapeutic tyranny," which cautioned against condemning a patient "to an artificially prolonged agony."

We now turn our attention to your central argument that nutrition/hydration is not a "medical act," but rather "normal care." You describe it as "a natural means of preserving life" when it is capable of achieving its own proper finality of providing nourishment--when it achieves its purpose. That is, it is "basic care," and hence "ordinary and proportionate," and obligatory, when it maintains life by sustaining adequate nutrition and hydration. We believe that making this argument will be challenging. We suggest, first, that it may be helpful for you to describe in detail the different methods of meeting nutritional needs artificially, such as hyperalimentation, nasal-gastric tube, peg or J-tube, or IV. Each of these entails invasiveness, risks, and limitations on usefulness, as well as such medical expertise as anesthesiology, surgery, radiology, dietary, and general nursing. You may find you want to nuance your argument to include only some forms of artificial administration as "basic care."

Another challenge to this argument will stem from the tradition's usual understanding of ordinary and proportionate care as referring not to the ability of some intervention to achieve its purpose, but to its ability to offer what McFadden called "the sound hope of providing benefit" by doing so. The Declaration makes this same point stating, "it is also permitted to interrupt these means where the results fall short of expectations," not simply because they fail to achieve their purpose or are burdensome (emphases ours).

We would also call your attention to the language traditionally employed in such discussions. The Declaration speaks of "techniques" and "remedies," not the "medical act/natural means" distinction you propose. Your project will need to show how this new designation better serves a tradition that has not heretofore recognized the need for it.

Finally, we would like to make one comment on your use of sources. In one place you write, quoting the Declaration, that "there is an obligation to provide the 'normal care due to the sick in such cases.'" But citing "normal care" as obligatory is curious. Your thesis is not that there is an obligation to provide normal care, which this reference would support, but that "normal care" includes artificially administered nutrition and hydration. The Declaration does not address this issue, so your reference to it here may be misleading. More problematic is your reference to the Charter, which you cite as stating, "normal care ... includes, in fact, the use of nutrition and hydration." The 1995 Pontifical Council's Charter actually reads," administration of food and liquids, even artificially, is part of the normal treatment always due to the patient when this is not burdensome for him" (emphases ours). You will want to use greater care in your final project.

We are hopeful that you will find these comments useful as you continue your work.

Sincerely,

Your Thesis Committee 

Reverend John F. Tuohey holds the endowed chair in applied healthcare ethics at Providence St. Vincent Medical Center in Portland, Oregon.