Should patients in a “vegetative state” (VS), whose condition has been diagnosed with moral certainty as irreversible after a year or more, continue to be given food and water by artificial means? That was the issue debated at a recent conference in Rome which concluded with Pope John Paul II affirming that it should be. Withdrawing food and water, he said, amounted to “euthanasia by omission”. For the Pontifical Academy for Life and the World Federation of Catholic Medical Associations, which have argued for this conclusion, the Pope’s statement has brought to an end a long-standing ethical debate within the Church.
But as this door closes, others have swung open, revealing more questions. What wriggle room is now left for doctors in Catholic hospitals to continue to make decisions on a case-by-case basis? What guidelines now need to be drawn up by Catholic healthcare organisations, and how should they read? How definitive is this pronouncement, and where does it leave teaching on the issue by bishops and by the Pope himself at variance with his conclusion?
The last time John Paul II spoke on this issue was to a group of American bishops in 1998. The presumption, he said on that occasion, was in favour of providing medically assisted nutrition and hydration (MANH) to all patients who needed it. This left doctors morally free to use their professional judgement.
What was not in dispute at the Rome conference was that MANH should be given to all patients in acute care and to all conscious patients unless they did not want it – due to loss of appetite, for example, or its burdens. But patients in a permanent vegetative state (PVS) are unable to show their wishes. PVS patients are awake but not conscious (unlike a coma, in which the patient is neither awake nor aware). In PVS the brain is badly damaged but the brainstem is alive, maintaining functions such as breathing. The patients are unconscious, unaware of themselves or their environment. They apparently lack the instinct to eat or drink and do not experience pain, which is a physico-psychological state. MANH for vegetative patients sustains life but it can also be viewed as force-feeding by tube into the stomach or through the nose.
The arguments in favour of prolonging PVS are clear. Human life is a gift from God; it is a basic good of the person and not merely a means to other goods. Life should be preserved by the use of ordinary or reasonable means, and without unjust discrimination against the vulnerable and the disabled, who include permanently unconscious patients. Wherever there is a reasonable doubt on a question of human life, furthermore, it should be resolved in favour of life: MANH sustains life for patients who can assimilate it and may prevent suffering from dehydration, hunger and thirst. Permanently unconscious patients should not be deprived of MANH, therefore, if it is their only means of sustaining life.
It is also argued that a condition that causes unconsciousness may not, in itself, be a fatal pathology: such patients can live for a long time if they are provided with MANH. Nor can PVS be diagnosed with total certainty – there have been cases where patients deemed vegetative have shown signs of being able to communicate by computer. The withdrawal of MANH from PVS patients, the argument runs, must therefore be euthanasia, because it involves a deliberate choice that brings about death.
At the conference Pope John Paul II noted that “the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act.” Its use, he said, was “in principle ordinary and proportionate, and as such morally obligatory to the extent to which and in so far as it is seen to achieve its proper purpose which in the present case consists in providing nourishment to the patient and alleviation of his suffering.” He went on: “Death by starvation or dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission.”
And yet when the withholding of treatment is morally justified, generally its withdrawal is justified. If a ventilator may be ethically withdrawn from a permanently unconscious patient, why the reluctance to withdraw MANH from a permanently unconscious patient? Both, after all, use a medical procedure; in both cases death is the natural outcome unless ventilation or MANH is continued. Air and food are equally necessary for the maintenance of spontaneous life. If the ventilator may be ethically withdrawn, why not also MANH? Is the withdrawal of MANH necessarily morally the same as deliberately choosing to cause death?
Indeed, once a patient is diagnosed with moral certainty to be permanently unconscious, it seems to be contrary to his or her human dignity to delay inevitable natural death by MANH. While every human life is worth living, the use of MANH to prolong indefinitely the life of a patient in a permanent unconscious state does not seem to respect that worth. Is it not lack of respect for a patient’s inherent dignity to be subjected to years of unconscious life sustained by MANH? How, then, can withdrawal of MANH in such cases be unethical – even euthanasia by omission?
Life is a basic good of the patient that should never be deliberately terminated. But does it follow that there is a moral duty indefinitely to provide MANH for permanently unconscious patients? The Catholic bishops of Texas thought not in 1990, when they observed: “The morally appropriate foregoing or withholding of artificial nutrition and hydration from a permanently unconscious person is not abandoning that person. Rather, it is accepting the fact that the person has come to the end of his or her pilgrimage and should not be impeded from taking the final step.”
In his encyclical letter, Veritatis Splendor, Pope John Paul II wrote that “it is precisely these goods which are the contents of the natural law and hence that ordered complex of ‘personal goods’ [bonorum pro persona, ‘goods for the person’] which serve the ‘good of the person’: the good which is the person himself and his perfection. These are the goods safeguarded by the Commandments.” Goods, in other words, are for the good of the person. But it is not clear that the duty to continue indefinitely MANH to sustain the life of permanently unconscious patients serves their good; nor that to withdraw MANH necessarily violates their good.
It was agreed by all congress participants that it would be immoral to give a lethal injection to a PVS patient; this would be acting against the fundamental value of the good of the life of the patient. The Pope has, however, ruled that MANH is ordinary care – that is, there is a duty to provide MANH; its withdrawal therefore would be euthanasia by omission, i.e., a deliberate decision contrary to the fundamental good of the life of the patient. I accept this teaching by the Pope; it applies in principle and does not rule out the ethical use of professional judgement by doctors should medical counter-indications arise.
What Pope Pius XII said in 1957 is very helpful on how to distinguish ordinary and extraordinary means of medical treatment: ordinary means, he said, were those “that do not involve any grave burden for oneself or another”. The determination of what is a “grave burden” would depend on clinical judgement. It will also depend on other circumstances: what would be ordinary (that is, non-burdensome) for a hospital in the United Kingdom would often be extraordinary for another in rural Africa. The Pope also accepts that MANH should not be continued in the event that it does not in fact provide nourishment (if, for example, it cannot be assimilated) or if it causes pain or suffering to the PVS patient. These two points leave scope for the exercise for professional judgement and decision by doctors.
Pope John Paul’s conclusion may be refined if there are significant developments in research. The conference heard evidence that some PVS patients had minimal consciousness, and that there was a possibility they could experience pain. If it is confirmed that PVS patients could experience pain or are self-conscious but unable to show it, then it would seem to argue in favour of not continuing MANH indefinitely; the alternative could subject them to psychological torture. It is also well established that loss of appetite is part of the dying process. Might MANH not override the natural dying process of patients in this condition?
New evidence that may be relevant for refining the Pope’s teaching will need to be looked at carefully and evaluated. And in drawing up guidelines for Catholic hospitals in the light of the Pope’s authoritative but non-definitive teaching bishops will need to pay careful attention to the predicament of staff and family who find they are in conscience unable to accept it.