John Paul II on the "Vegetative State"

Richard M. Doerflinger
March 20, 2004
Reproduced with Permission

In a March 20 address, Pope John Paul II made a very significant contribution to an ethical debate that has troubled Catholic ethicists in the United States and elsewhere for many years: The feeding of patients diagnosed as being in a "vegetative" state.

His speech was addressed to participants in an international congress titled "Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas," co-sponsored by the Pontifical Academy for Life and the International Federation of Catholic Medical Associations. The congress was attended by physicians, scientists, ethicists, and others from over forty countries.

The Holy Father's address touched upon at least four aspects of this issue.

Main Points

First, a statement of theological anthropology. Against all who would deny the inherent worth and human dignity of persons in a "vegetative" state, the Holy Father strongly affirmed that

the intrinsic value and personal dignity of every human being do not change, no matter what the concrete circumstances of his or her life. A man, even if seriously ill or disabled in the exercise of his highest functions, is and always will be a man, and he will never become a "vegetable" or an "animal." Even our brothers and sisters who find themselves in the clinical condition of a "vegetative state" retain their human dignity in all its fullness. (n. 3, original emphasis)

Second, a recognition of the latest medical and scientific findings on the "vegetative" state, reviewed at length during the congress itself. Misdiagnosis of the "vegetative" state is common, prognoses (including predictions that patients can never recover) are far from reliable, and the assumption that this state of unresponsiveness entails complete absence of internal sensation or awareness is being seriously questioned.

Third, a statement of medical ethics. Patients in this state deserve the normal care that is due all patients out of respect for their human dignity, including nutrition and hydration.

I should like particularly to underline how 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. (n. 4, original emphasis)

Fourth, a statement of social ethics. Families caring for patients in this state should not be abandoned to suffer alone but must receive all possible support from society, including appropriate "respite care" and other practical help.

Many ethicists will focus on the third statement, which makes a stronger and more explicit statement in favor of providing food and fluids to these patients than has been seen from authoritative Vatican sources. To ignore the other elements of the Holy Father's address, however, would wrench this specific norm out of its context in a profound theology of the human person, an understanding of the latest scientific data, and a heroic social ethic demanding that the burdens of caring for the most helpless should be borne by all.

Affirmation of Human Dignity

Three questions have been at the heart of Catholic moral debate on providing food and fluids to the patient in a "vegetative" state. Does the life of such a patient have the same inherent value and dignity as the lives of others, placing essentially the same moral demands on us for care despite the person's low "quality of life"? Is such a state generally to be seen as a severe condition of disability demanding assistance from others, rather than as a "terminal" illness which morally can be allowed to run its course toward death? Is artificially assisted food and fluids to be seen as a form of "normal care" care owed in principle to all patients?1 The Holy Father answers all these questions in the affirmative.

His insistence on the full value and dignity of these patient's lives, and his warning against external judgments attributing "increasing and decreasing levels of quality of life, and therefore of human dignity," to patients, seems a direct response to a theory held by many theologians in the United States for some years. According to that theory, there is generally no moral obligation to sustain the life of a patient in a "vegetative" state, even by food and fluids, because such a patient can no longer pursue the "spiritual purposes" to which human life is ordered; to feed and maintain this patient indefinitely only preserves a "biological existence" incapable of engaging in human acts. In the March 20 speech, by contrast, the decisive fact is the patient's inherent dignity as a human being and his or her status as a child of God, in need of care and support - not the kinds of acts that may make a life seem worthwhile to an outside observer.

The "spiritual purposes" standard for withdrawing food and fluids has been challenged before. In 1992, after two years of research and drafting, the U.S. bishops' Committee for Pro-Life Activities issued a resource paper titled "Nutrition and Hydration: Moral and Pastoral Reflections."2 The paper concluded that withholding or withdrawing medically assisted nutrition and hydration is a form of euthanasia by omission when the intent is to end life. It found that nutrition and hydration are generally a form of "ordinary care," or at least an ordinary means of sustaining life, because they are basic needs which are effective in sustaining life (except for the imminently dying patient) and do not often impose grave burdens on the patient. The paper warned against the use of "quality of life" judgments to dismiss the value of disabled patients' lives. Finally, while recognizing that theological debate would continue, it found the "spiritual purposes" theory unconvincing, instead recommending a presumption in favor of assisted feeding for patients in the "vegetative state."

The 1992 paper's general conclusions were reflected in the 1995 revision of the U.S. bishops' Ethical and Religious Directives for Catholic Health Care Services which govern practice in Catholic health facilities. That edition, and the 2001 revision now in effect, state: "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 outweigh the burdens involved to the patient" (directive 58). And in 1998, the Holy Father singled out the Pro-Life Committee's paper for praise while speaking to a group of U.S. bishops:

The statement of the U.S. bishops' pro-life committee, 'Nutrition and Hydration: Moral and Pastoral Considerations,' rightly emphasizes that the omission of nutrition and hydration intended to cause a patients death must be rejected and that, while giving careful consideration to all the factors involved, the presumption should be in favor of providing medically assisted nutrition and hydration to all patients who need them.3

"Spiritual Purpose" Rationale

The Holy Father's new speech is more forthright than past U.S. bishops' statements in identifying assisted feeding as part of the "normal care due to the sick" even in cases where specific medical treatments have been withdrawn. On this point, however, there is precedent in documents issued by several Vatican advisory bodies in recent years, including the Pontifical Council Cor Unum and the Pontifical Council for Pastoral Assistance to Health Care Workers. In 1995, for example, the latter body's Charter for Health Care Workers stated: "The 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: their undue suspension could be real and properly so-called euthanasia" (n. 120).

Late in 2002, a leading proponent of the "spiritual purpose" rationale for withdrawing assisted feeding from patients in a vegetative state expressed concern over recent statements by Church officials and Vatican theologians on life support, beginning with certain passages of the Holy Father's 1995 encyclical Evangelium vitae. He suggested then that a "development of doctrine" may be taking place, narrowing the circumstances under which assisted feeding and other life support may be withdrawn.4 Whether one sees this trend as a development of doctrine will depend on one's interpretation of Church teaching prior to 1985; in any case, this account shows that the Pope's new speech is not a radical shift but the culmination of a longstanding trend at the Vatican.

Notably, in the March 20 speech, food and fluids are identified as normal care not only to emphasize the strong presumption in favor of their use, but also to counter an argument sometimes used to justify their withdrawal from seemingly incurable patients: The argument that such means should be assessed in terms of whether they lead to recovery from the patient's underlying condition. The Holy Father emphasizes that assisted feeding is not a "medical act" in this sense - that is, it should not be dismissed as useless or "extraordinary" because it preserves life and prevents a death from starvation or dehydration but does nothing more. Life itself is sufficient reason to continue such support.

The evaluation of probabilities, founded on waning hopes for recovery when the vegetative state is prolonged beyond a year, cannot ethically justify the cessation or interruption of minimal care for the patient including nutrition and hydration. (n. 4, original emphasis)

In this commentator's view, the Holy Father has not declared an absolute moral obligation to provide assisted feeding in all cases, regardless of whether it effectively provides nourishment or might in a given case impose grave suffering and other burdens on a patient. But he has established the provision of food and fluids as a general norm for all helpless patients, including those who seem completely unresponsive to the outside world. It is in serving those who may never visibly respond to our care that we find the ultimate test of our Christian charity and our respect for the inherent dignity of each human life.


1 Congregation for the Doctrine of the Faith, Declaration on Euthanasia, part IV. [Back]

2 See [Back]

3 "Building a Culture of Life," 'ad limina' address to the bishops of California, Nevada, and Hawaii (October 2, 1998), Origins 28.18 (October 15, 1998): n. 4. [Back]

4 Rev. Kevin O'Rourke, "Ms. 'B' and the Vatican," National Catholic Bioethics Quarterly 2.4 (Winter 2002): 600. [Back]