The Terri Schiavo effect
Father Thomas Berg explains the bishops’ new directives on feeding the disabled . . .
Ethical debate about providing patients with artificial nutrition and hydration has intensified over the past five years since the case of Terri Schindler Schiavo, the brain damaged Florida woman whose husband successfully fought to have her feeding tube removed. Deprived of nutrition and hydration, she died on March 31, 2005 — 13 days after judges ordered the tube removed.
Last November, U.S. bishops voted to revise their Ethical and Religious Directives for Catholic Health Care Services (ERDs) on the issue of providing patients — particularly those lingering in a “persistent vegetative state” (PVS) — with artificial nutrition and hydration (ANH). The ERDs are intended to offer authoritative moral guidance to Catholics on difficult moral questions.
The revision of ERD 58 now makes clear that patients with chronic conditions like PVS, and who are not imminently dying, should receive food and water by “medically assisted” means if necessary. The directive now states:
“In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic and presumably irreversible conditions (e.g., the ‘persistent vegetative state’) who can reasonably be expected to live indefinitely if given such care.”
The ERDs were last revised in 2001. At the time, there was still an unsettled question among Catholic ethicists as to whether there was a moral requirement to provide ANH to patients in PVS. Some opined that provision of ANH to such patients would constitute “extraordinary” (and therefore morally optional) medical care. In 2001, Directive 58 stated that there should be a “presumption in favor of providing nutrition and hydration” to such patients.
Finally, in 2004, Pope John Paul II provided a more specific clarification on this question. In his address to the participants in the international congress on “Life-Sustaining Treatments and Vegetative State,” the Pope clarified that for such patients: “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, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering.”
It was on the basis of this statement and subsequent clarifications from the Congregation for the Doctrine of the Faith in 2007 that Directive 58 was edited last fall. What specifically does this mean and what conclusions can we draw from it?
• Clinical protocols that would indiscriminately withhold or remove ANH from such patients, without due regard for the moral guidelines articulated in Directive 58, leave death by starvation or dehydration as the logical outcome. John Paul wrote that such an omission could constitute “true and proper euthanasia.” Catholic health care facilities must assure that their protocols are in line with Directive 58 — including their policy regarding patient requests to be deprived of ANH.
• Provision of food and water are to be considered a part of normal care giving (not an “extraordinary means”), even when provided artificially as with the assistance of a gastric feeding tube (granted that its insertion is, in fact, a medical procedure, that its maintenance requires periodic attention from a health care professional, and that there are financial considerations involved).
• This teaching certainly extends beyond the specific case of persons in PVS to include any patient suffering a pathology that makes them unable to assimilate food and water without artificial assistance, such as advanced Alzheimer’s disease or acute dementia.
• Under what circumstances could Catholic patients in good conscience withhold or withdraw ANH? Directive 58 states that such provision is obligatory “in principle.” The possible exceptions to that obligation are fairly narrow, however.
ANH is not obligatory when it cannot reasonably be expected to prolong life, when it is judged to constitute an “excessive burden” for the patient (as in the rare instance that it might cause “significant physical discomfort”) or when the patient can no longer assimilate food and water (as when death is imminent).
Determining if and when ANH can be removed will normally require consultation between family and care-givers, attending physicians and, if necessary, a priest or ethicist trained in the Church’s moral teaching on such matters.
• Consequently, Catholics considering end-of-life decisions should adhere to the moral truths affirmed in the revision of Directive 58 and plan their health care accordingly. It would be immoral for them to indicate in their “living wills” or advance medical directives a desire to forgo or have withdrawn the provision of food and water if they should suffer severe cognitive impairment.
In sum, the revision of Directive 58 underscores the moral complexity of contemporary health care, as well as the competence of the Church in providing solid moral guidance on such complex moral issues. It reminds us, moreover, that those who find themselves in impaired states requiring the administration of ANH retain their full human dignity until their natural demise. “The loving gaze of God the Father,” wrote John Paul II, “continues to fall upon them, acknowledging them as his sons and daughters, especially in need of help.”
Rev. Thomas V. Berg is a priest in the Archdiocese of New York and executive director of the Westchester Institute for Ethics & the Human Person.