To feed or not to feed: Terri Schiavo and the use of artificial nutrition and fluids.

The recent events surrounding the case of Terri Schiavo have illuminated the moral implications of modern medicine in regards to artificially sustaining life. Among the issues raised by Terri's parents against the withdrawal of the feeding tube was that such an action would be euthanasia and would violate their daughter's Catholic religious beliefs. The split within the family, the emotionally charged rhetoric, and the political posturing in this case have drowned out both rational discourse and historical memory. This turmoil has led some politicians and even a few bishops and cardinals to denounce the removal of Terri Schiavo's feeding tube as "euthanasia" or "murder." However, this interpretation of the Catholic position on the sanctity of life is not consonant with traditional Church teaching.

The Schindler family's perception of Catholic teaching is understandable, particularly in light of the late Pope John Paul's speech regarding the care of patients in a persistent vegetative condition: "The administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act ... and as such is morally obligatory." (1) This forms the basis of the Schindler family's belief that since nutrition and hydration are necessary for life, the denial of these basic needs constitutes murder.

The parents' position is highly problematic, however, because it is incompatible with 400 years of consistent Catholic moral teaching regarding the measures by which one should preserve life. In 1595, Domingo Banez (2) expounded upon the foundational views of the moralist Francisco de Vitoria (3) by drawing the distinction between "extraordinary" and "ordinary" means of preserving life. Examples of extraordinary means may include excessive cost or burden, or lack of substantial benefit to the patient, therefore relieving the moral obligation to sustain life.

That the doctrine has continued unchanged to the present day is seen in the Vatican's 1980 "Declaration on Euthanasia," which states: "One cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide [or euthanasia]; on the contrary, it should be considered as an acceptance of the human condition." (4)

In 2001, the United States Catholic bishops developed a set of national guidelines outlining the practical implications of Church teaching for patient care in Catholic hospitals. (5) Two such directives are of immediate consequence. Directive 57 states: "A person may forgo means that in the patient's judgment do not offer a reasonable hope of benefit, or entail an excessive burden, or impose excessive expense on the family or community." This directive gives the patient the right to choose, even if that choice is accepting death. The second of these, Directive 58, reads: "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 the patient." Such language implies that there are situations where the moral imperative to preserve life is lifted.

The position that one might legitimately withdraw a feeding tube is not limited to Catholic moral theologians. It has also been addressed in recent years by the courts, the medical community and the public. The California Court of appeals addressed the issue in Barber v. Superior Court (1983) (6) when it dismissed a first degree murder indictment against two physicians who, at the request of the family, withdrew a feeding tube from a patient judged to be irreversibly comatose. The Court held that the physicians' action did not "kill" the deceased. Rather, the Court ruled that the cause of death was the underlying neurologic pathology that prevented the patient from swallowing.

The American Medical Association's Council on Ethical and Judicial Affairs adopted a similar position in 1986 when it held that, "Even if death is not imminent but a patient's coma is beyond doubt irreversible ... and with the concurrence of those who have responsibility for the care of the patient, it is not unethical to discontinue all means of life-prolonging treatment." The Council went on to note that "Life prolonging medical treatment includes medication and artificially or technologically supplied respiration, nutrition and hydration." (7)

The United States Supreme Court's 1990 Cruzan v. Director opinion made it clear that "the United States Constitution would grant a competent person a constitutionally protected right to refuse life-saving hydration and nutrition." (8) In addition, the Supreme Court ruled that the right to refuse such medical treatment also applies to incompetent patients, as based upon their presumed wishes, while remaining subject to the established standards of the individual states.

Much of the Supreme Court's moral and legal analysis was forgotten in the politicized debate over Terri Schiavo's fate. In his official statement Schiavo's own bishop, Robert N. Lynch of St. Petersburg, avoided the politics that had so marred this case and made no charge of euthanasia. He proposed that medical decisions "must be made on a case-by-case basis by families and/or other responsible parties at the clear direction of each one of us well in advance of a crisis." (9) In addressing the specific issue of the use of artificial nutrition and fluids Bishop Lynch used the language found in the Florida Catholic Conference's "Advance Directive," to note that a feeding tube need be utilized only "so long as it is of sufficient benefit to outweigh the burdens involved to the patient." (10)

The Roman Catholic Church has always taught the sanctity of life. Such a teaching has led many to misinterpret this tradition as a precept to preserve and protect life at all costs. This misconstrual was central to the case of Terri Schiavo, particularly in light of Pope John Paul's 2004 statement exhorting a responsibility to preserve life, through the continued administration of basic nutrients. The Pope's statement, however, must be taken within the context of Catholic tradition. That tradition does not exclusively insist upon preserving life. In fact, the tradition makes it clear that if there is no further physical or spiritual benefit to be gained in sustaining life, then there is no moral obligation to do so.

References

1. Address of Pope John Paul II to the Participants in the International Congress on Life-Sustaining Treatments and Vegetative States: Scientific Advances and Ethical Dilemmas. Origins 2004;33:738-740.

2. Smith RE. Ordinary and Extraordinary Means. Ethics Medics 1995;20.

3. McCartney JJ. The Development of the Doctrine of Ordinary and Extraordinary means of Processing Life in Catholic Moral Theology Before the Karen Quinlan Case [Relations Theologicae]. Linacre Quarterly 1980;47:215-226.

4. Deciding to Forego Life-Sustaining Treatment. In, President's Commission for the study of Ethical Problems in Medicine and Biomedical Research, Buffalo, William S. Hein & Company, 1980.

5. US Conference of Catholic Bishops. Ethical and Religious Directives for Catholic Health Care Services. 4th ed. Washington, DC, National Conference of Catholic Bishops, 2001.

6. Barber v Superior Court, 147 3d 1006 (CA App 1983).

7. American Medical Association, Current Opinions of the Council on Ethical and Judicial Affairs, 1986. [section] 2.18.

8. Cruzan v Director, Missouri Department of Health, 497 US 261 110 S Ct 2841 (1990).

9. Lynch RN. Lynch Concerning the Removal of the Feeding Tube of Terri Schiavo [Florida Catholic Conference Web site]. Available at: http://www.flacathconf.org. Accessed October 15, 2003.

10. Lynch RN. Lynch Concerning the Terri Schiavo Case [Florida Catholic Conference Web site]. Available at: http://www.flacathconf.org. Accessed August 12, 2003. http://www.flacathconf.org

Shallow men believe in luck. Strong men believe in cause and effect.
--Ralph Waldo Emerson

John J. Paris, SJ

From the Theology Department, Boston College, Boston, MA.

Reprint requests to John J. Paris, Theology Department, Boston College, 21 Campanella Way 316, Chestnut Hill, MA 02467. Email: [e-mail]

Accepted May 6, 2005.