Saturday, September 15, 2007

Nutrition and Hydration and the Catholic Church

The Vatican has issued an opinion on care for patients in a persistent vegetative state. Specifically, the Congregation for the Doctrine of the Faith has reaffirmed statements made in 2005 in the contexts of the deaths of both Terry Schiavo and Pope John Paul II. The opinion affirms that it is the teaching of the Roman Catholic Church that providing nourishment and fluids is “ordinary care” rather than “extraordinary” or “heroic care,” even when the nourishment and fluids are provided through tubes in mouth or nose or belly instead of by eating and drinking and swallowing. There are news reports here and here.

The text of the statement is brief enough I can include it in full:


First question: Is the administration of food and water (whether by natural or artificial means) to a patient in a “vegetative state” morally obligatory except when they cannot be assimilated by the patient’s body or cannot be administered to the patient without causing significant physical discomfort?

Response: Yes. The administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life. It is therefore obligatory to the extent to which, and for as long as, it is shown to accomplish its proper finality, which is the hydration and nourishment of the patient. In this way suffering and death by starvation and dehydration are prevented.

Second question: When nutrition and hydration are being supplied by artificial means to a patient in a “permanent vegetative state”, may they be discontinued when competent physicians judge with moral certainty that the patient will never recover consciousness?

Response: No. A patient in a “permanent vegetative state” is a person with fundamental human dignity and must, therefore, receive ordinary and proportionate care which includes, in principle, the administration of water and food even by artificial means.

There are some interesting points for exploration in this brief statement. First, the “proper finality” (that is, the appropriate end or purpose) of nutrition and hydration is that “suffering and death by starvation and dehydration are prevented.” Unfortunately, there is evidence that for some patients keeping the stomach functioning can in fact cause pain and suffering. At the same time, one must raise the question of just what “suffering” a patient in a persistent vegetative state can experience. Across the broad spectrum of patients who lack cognitive capacity (medicated, comatose, persistent vegetative state or the relatively new category of minimally conscious state), it would seem pertinent to consider the specific capacities and responses of the patient. It is worth noting, though, that the Roman Catholic Church has not denied the concept of brain death in this statement, nor in any other of which I am aware.

More interesting is the second statement: “A patient in a “permanent vegetative state” is a person with fundamental human dignity and must, therefore, receive ordinary and proportionate care which includes, in principle, the administration of water and food even by artificial means.” This is an important expression of the Vatican’s understanding of personhood. “Fundamental human dignity” is not dependent on cognitive capacity, relational ability, or expectation of survival.

This expresses, I think, the principle that our “fundamental human dignity” is not inherent in us. Rather, we have human dignity because God dignifies us. We are God’s creatures, created in his love, with capacity for relationship with him, and thus in God’s “image and likeness.” God dignified us in willingness to become one of us, and to die that we might live. God continues to dignify us in accepting us into Christ’s Body, and dwelling in us in the Holy Spirit. Since our human dignity is God’s grace, and not our own possession, we are called to act carefully and thoughtfully in making decisions at the end of life.

This, however, does not make “extraordinary” care obligatory. And that is one point where this is commonly discussed. We all appreciate eating and drinking and swallowing are ordinary; but just how ordinary is passing liquid foods through a tube through the abdominal wall, much less passing chemicals through a needle into a vein? In principle, nourishing and hydrating ourselves is ordinary. Just how far from that can the method stray and still be “ordinary?” We also breathe normally; and yet maintaining a patient on a mechanical ventilator is “extraordinary” care. At what point do means, and our lack of capacity to control means, inform the principle?

Too, how absolute are our understandings of “fundamental human dignity?” More to the point, when do we cease to be meaningfully “human?” Our dignity may be a reflection of God’s grace; but surely we would not want to say that there is no ending of that. We trust God’s grace is still somehow relevant to the “Church Expectant,” those who have died before us; but we would not, I think, say that their dignity was not changed by their death. Certainly, the Roman Catholic Church has not said that. There is within the Roman Catholic culture for health care a concept of “extraordinary care” that is not obligatory. The concept of brain death is accepted, as is the concept of donation of one’s organs and tissues.

And if we do associate God’s “image and likeness” in us with the capacity to relate and to love, how does that change when we can no longer relate in love to one another? In one sense, perhaps it doesn’t; for, again, we accept that somehow God’s love and grace are still relevant to the “Church Expectant.” At the same time, we do not think of the dead as human in the same way, whatever their history in life or the promise of resurrection in their future. We distinguish between brain death, and irreversible brain injury just short of that, and persistent vegetative state, not in whether the patient will die, but in how soon.

Clearly, the Roman Catholic Church has drawn a somewhat arbitrary line. That in and of itself does not bother me. After all, choosing any point between “any life is life, and anything we might do to keep organic function going is obligatory;” and “let’s not waste precious resources on those who aren’t going to get better, even if right now they’re not getting any worse” is somewhat arbitrary. We will all have our arguments for our position, but sooner or later we make a decision of what we will live with and what arguments we find compelling (for, after all, at some point “it’s turtles all the way down.”)

At the same time, I an acutely aware of how this will impact Roman Catholic patients and families, and Roman Catholic providers, both individual and institutional. They function, as we all do, in a culture that seems to struggle between a concept of “fundamental human dignity” and a sense that human dignity is based on function, whether in relationship or in occupation or in social recognition. They will be stressed sometimes in determining “the right thing to do.” And in some cases I and the folks I work with will be involved in helping them make that decision.

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