The universal Magisterium of the Roman Catholic Church has provided guidance in "artificial nutrition and hydration" [henceforth ANH] matters and expounded the principles essential to this moral issue.1 In this paper, I will consider some of the Magisterial documents of the Holy See such as Pontifical statements and instruction, as well as the publications of Pontifical Agencies and National committees, especially that of the U.S. committee.
I will also argue that The Congregation for the Doctrine of the Faith in their Declaration on Euthanasia (1980) and The Catechism of the Catholic Church (1984) provides a detailed examination for ANH and for any moral judgments.
Pope Pius XII in his address2 to the anaesthesiologists who gathered in Rome on November 24, 1957 responded to three questions regarding resuscitation and the validity of extreme cases, stating that people have a duty to conserve lives out of charity and justice:
But normally one is held to use only ordinary means - according to the circumstances of persons, places, times and culture - that is to say, means that do not involve any grave burden for oneself or another. A stricter obligation would be too burdensome for most men and would render the attainment of the higher, more important good too difficult. Life, health, all temporal activities are in fact subordinated to spiritual ends. On the other hand, one is not forbidden to take more than the strictly necessary steps to preserve life and health, as long as one does not fail in some more serious duty…3
The "higher goal/spiritual goal" that Pope Pius XII referred to is eternal life. God is the giver of all life and we only ever hold this precious gift of life in trust for a certain time. To interpret the statement of Pope Pius XII correctly, it is not only necessary to "weigh" the benefits and burdens according to each patient's situation, but more importantly, to relate these benefits and burdens to the higher goal and/or spiritual goal of a human's life; then using the concept of ordinary and extraordinary means pursue the morally acceptable course according to that principle.
Moreover, there is another general statement noted by some moral theologians and ethicists that Pope Pius XII believed that physicians and nurse have the moral obligation to employ those ordinary means over a patient life.
It remains for the doctor, and especially the anaesthesiologist, to give a clear and precise definition of "death" and the "moment of death" of a patient who passes away in a state of unconsciousness. Here one can accept the usual concept of complete and final separation of the soul from the body; but in practice one must take into account the lack of precision of the terms "body" and "separation."… In case of insoluble doubt, one can resort to presumptions of law and of fact. In general, it will be necessary to presume that life remains, because there is involved here a fundamental right received from the Creator, and it is necessary to prove with certainty that it has been lost.4
Pope John Paul II in his numerous writings and addresses, especially to health-care professionals, presents general Christian principles essential to ethical decisions in modern medicine in regards to the uniqueness and corporal integrity (body and soul) of the human person. Central to all his writings and addresses is the affirmation that God is the Creator of human life and only He is the Lord of life. Medical science with its modern advances can be only properly understood in the service of the human person.5
For our research is not necessary to present all of Pope's John Paul II writings, but it is necessary to examine his address to the International Congress for The World Federation of Catholic Medical Associations and Pontifical Academy for Life on "Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas."6 The Pope in his address presented a general principle for providing nutrition and hydration to those in a PVS. According to the Pope John Paul II,
The sick person in a vegetative state, awaiting recovery or a natural end, still has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.), and to the prevention of complications related to his confinement to bed… 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…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.7
Among Catholic ethicists and moral theologians, this address is still a topic for discussion, because the Pope's address does not expound Church teaching in regards to providing nutrition and hydration to those in a PVS; neither is this address related to questions such as the ethical significance of the modes of delivery of ANH or the significance of the imminence of death. However, the Pope's affirmation about the dignity of every human person, based on human nature itself has to be taken into account.8
The Congregation for the Doctrine of the Faith [henceforth CDF] issued two important declarations which are relevant to our theme: the Declaration on procured Abortion (1974)9 and the Declaration on Euthanasia (1980).10
In 1974, the CDF issued the Declaration on procured Abortion, which profoundly developed the theological understanding of human life and also described the necessity to preserve and respect human life from the beginning. A chapter relevant to our discourse is titled "In the Additional Light of Reason," where the Declaration develops respect for human life based on reason and natural law.
Respect for human life is not just a Christian obligation. Human reason is sufficient to impose it on the basis of the analysis of what a human person is and should be. Constituted by a rational nature, man is a personal subject capable of reflecting on himself and of determining his acts and hence his own destiny: he is free. He is consequently master of himself; or rather, because this takes place in the course of time, he has the means of becoming so: this is his task. Created immediately by God, man's soul is spiritual and therefore immortal.11
The person possesses as his own a level of life that is more profound and that cannot end. Bodily life is a fundamental good, here below it is the condition for all other goods. But there are higher values for which it could be legitimate or even necessary to be willing to expose oneself to the risk of losing bodily life.12
Therefore, the Declaration also addresses in a significant statement that human life has value at all stages of life.
Any discrimination based on the various stages of life is no more justified than any other discrimination. The right to life remains complete in an old person, even one greatly weakened; it is not lost by one who is incurably sick.13
The Declaration on procured Abortion clearly develops general and theological principles relevant to human life and necessary for any ethical considerations.
This brings us to another declaration issued by the CDF on May 5, 1980, the Declaration on Euthanasia. The declaration provides principles, though not explicitly, that can be applied to the withdrawal of ANH from a person, which is our concern in this research. From the very beginning, the Declaration makes a clear distinction between the etymological definition of euthanasia and the connotation of the word:
The word Euthanasia is used in a more particular sense to mean "mercy killing," for the purpose of putting an end to extreme suffering, or having abnormal babies, the mentally ill or the incurably sick from the prolongation, perhaps for many years of a miserable life, which could impose too heavy a burden on their families or on society.14
Moreover, the Declaration states a formal definition of euthanasia which provides the terms of reference for the moral description of the act. This definition has been lately used in many magisterial documents.
By euthanasia is understood an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated. Euthanasia's terms of reference, therefore, are to be found in the intention of the will and in the methods used.15
The Declaration also deals with the proportionate character of the traditional distinction between "ordinary" and "extraordinary" means of conserving life by offering the terms "proportionate" and "disproportionate" as alternative terms to indicate the same moral distinction denoted by the traditional moral terms. These new terms are especially helpful in cases like ANH or PVS.
In the past, moralists replied that one is never obliged to use "extraordinary" means. This reply, which still holds good, is perhaps less clear today, by reason of the imprecision of the term and the rapid progress in the treatment of sickness. Thus, the moralists today prefer to speak of "proportionate" and "disproportionate" means. In any case, it will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources.16
Therefore, we can find this new terminology as helping the moralist in making ethical decisions concerning the conservation of life. This is further demonstrated in the document by means of an example:
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; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community. When inevitable death is imminent in spite of the means used, it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted. In such circumstances the doctor has no reason to reproach himself with failing to help the person in danger.17
Finally, the Declaration states this fundamental conclusion about assisted ANH; it is obligatory until the final stage of dying and can only be withdrawn if it is prolonging the dying process.
The Pontifical Council Cor Unum study report. In November 1981, the Pontifical Council Cor Unum in their study report: Question of Ethics Regarding the fatally Ill and the Dying18 addressed issues of medical ethics. This report was issued after the publication of the Declaration on Euthanasia in 1980 and affirmed the teaching of the Catholic Church, but also analyzed more basic concepts.
Nonetheless, this report again elaborated the terminology and distinction between "ordinary" and "extraordinary," and distinguished between "objective" (such as availability and the cost of the means) and "subjective" (such as an individual's fear and repulsion) criteria:
The criteria whereby we distinguish extraordinary measures from ordinary measures are many. They are to be applied according to each concrete case. Some of them are objective: such as the nature of the measures proposed, how expensive they are, whether it is just to use them, and what options of Justice are in the matter of using them. Other criteria are subjective: such as not giving certain patients psychological shocks, anxiety, uneasiness, and so on. It will always be a question, when deciding upon measures to be taken, of establishing to what extent the means to be used and the end being sought are proportionate.19
Among all the criteria for decision, particular importance must be given to the quality of the life to be saved or kept living by the therapy. The fundamental point is that the decision should be made according to rational arguments that have taken well into account the many and various aspects of the situation, including what effect will be had upon the family. The principle to follow is, therefore, that no moral obligation to have recourse to extraordinary measures exists; and that, incidentally, a doctor must follow the wishes of a sick person who refuses the measures.20
Finally, this report is yet another example of the dicastery of the Holy See to specify the principles primarily based on the distinction between "ordinary" and "extraordinary" with specific criteria applicable in cases of feeding a patient in an irreversible coma.
The Pontifical Academy of Sciences study report. From the 19th to the 21st of October 1985, the Pontifical Academy of Sciences met to draft the study report titled: The Artificial Prolongation of Life and the exact determination of the moment of death.21
The report provides a working definition as to when the human person is understood to be dead.
A person is dead when he has irreversibly lost all ability to integrate and coordinate the physical and mental functions of the body" death comes when (a) the spontaneous functions of heart and breathing have definitively ceased, (b) the irreversible arrest of all brain activity. In reality 'brain death' is the true criterion of death, although the definitive arrest of cardio-respiratory activity very quickly leads to brain death.22
However, the report also describes the difference between treatment and care. Treatment is medical intervention, whatever its complexity. Care is ordinary help due to sick patients "such as compassion and affective and spiritual support."23 Lastly, the report explicitly speaks about a patient in an irreversible coma:
If the patient is in a permanent, irreversible coma, as far as can be foreseen, treatment is not required, but all care should be lavished on him, including feeding... If the treatment is of no benefit to the patient, it may be interrupted while continuing with the care of the patient.24
Given this fact, nutrition for patients in a PVS must be medically assisted, and the report once again states that assisted feeding for patients in a permanent coma is ordinary care.
The United States National Conference of Catholic Bishops for Pro-life Activities [henceforth NCCB] in 1992 issued the document - Nutrition and Hydration: Moral and Pastoral Reflections as a "resource paper," and entered the on-going theological debate as to whether artificial feeding is a morally "ordinary" or "extraordinary" means of conserving a patient's life who has been clinically diagnosed as being in a PVS.
The document has a long and complex history and its preparation had been ongoing for four years. The document was thoroughly discussed in a closed session of the executive of the NCCB and finally signed by members of the NCCB Administrative Committee and published not as a formal document of the NCCB, but as a committee statement.25
The Bishops acknowledged several necessary facts and principles in cases like assisted ANH and also different opinions by moral theologians in the Catholic Church in such cases.
Teaching of the Church has not resolved the question whether medically assisted nutrition and hydration should always be seen as a form of normal care…Catholic theologians may differ on how best to apply moral principles to some questions not explicitly resolved by the Church's teaching authority.26
The committee statement provided reflection on the various ethical and theological dimensions of the issue of providing ANH to a PVS patient. In the first part of the document, a committee statement addressed the relevant moral principles and elaborated upon them:
Everyone has the duty to care for his or her own life and health and to seek necessary medical care from others, but this does not mean that all possible remedies must be used in all circumstances. One is not obliged to use either "extraordinary" means or "disproportionate" means of preserving life - that is, means which are understood as offering no reasonable hope of benefit or as involving excessive burdens.27
The second contained questions relating to assisted ANH. In this part, the Bishops spoke of a situation where assisted ANH might be withdrawn.
Second, we should not assume that all or most decisions to withhold or withdraw medically assisted nutrition and hydration are attempts to cause death. To be sure, any patient will die if all nutrition and hydration are withheld… At other times, although the shortening of the patient's life is one foreseeable result of an omission, the real purpose of the omission was to relieve the patient of a particular procedure that was of limited usefulness to the patient or unreasonably burdensome for the patient and the patient's family or caregivers. This kind of decision should not be equated with a decision to kill or with suicide.28
Moreover, after establishing these facts, the Bishops ask the important question: What are the benefits of medically assisted nutrition and hydration?29 For answering this question, the Bishops dealt primarily with the intention.
Even here, however, we must try to think through carefully what we intend by withdrawing medically assisted nutrition and hydration. Are we deliberately trying to make sure that the patient dies, in order to relieve caregivers of the financial and emotional burdens that will fall upon them if the patient survives? Are we really implementing a decision to withdraw all other forms of care, precisely because the patient offers so little response to the efforts of caregivers? Decisions like these seem to reach beyond the weighing of burdens and benefits of medically assisted nutrition and hydration as such.30
The Roman Catholic Church has a long and consistent doctrinal tradition, rooted in divine law and natural law, which can bring considerable ethical clarity to the complex issues surrounding health care issues. A goal of this paper was to reaffirms basic principles of Catholic moral tradition concerning ANH issues and also to reaffirms that the teachings of the Catholic Church enables people to make just and compassionate decisions that effectively express their love for God. Love is the soul of the Church's life and teaching. This teaching is always referring to the central idea in Christian anthropology, that a human being is the unity of body and soul. It also points out to those who daily serve patients and remind them of the necessity of conversion in their conscience and the development of a greater appreciation of moral values and love in their lives. Only those who really live with the personal experience of the Lord's love are truly able to exercise the task of serving and accompanying others on the way of following the suffering and resurrected Christ.
1 See also the Catechism of the Catholic Church (U.S. Conference of Catholic Bishops, Office for the Catechism: The Vatican Library, 1994), no. 2258-2330; WORLD FEDERATION OF CATHOLIC MEDICAL ASSOCIATIONS AND PONTIFICAL ACADEMY FOR LIFE, "Considerations on the Scientific and Ethical Problems Related to Vegetative State," (Rome, March 17-20, 2004), in L'Osservatore Romano, 16 (April 20, 2004), p. 9; FLORIDA COUNCIL OF BISHOPS, Statement on the Life, Death, and the Treatment of Dying Patients (The Florida Catholic Conference, 1989); NATIONAL CONFERENCE OF CATHOLIC BISHOPS, Ethical and Religious Directives for Catholic Health Care Services, 5th ed. (Washington, D.C.:U.S. Catholic Conference, 1995), nn. 55-60, pp. 20-24. [Back]
2 The text is the Pope's Pius XII formal response to three questions submitted by Dr. Bruno Haid of the University of Innsbruck. PIUS XII, "Allocution 'Le Dr. Bruno Haid," in AAS (November 24, 1957), pp. 1031-1032. The commentary and application see Mark HUFTIER, "Usage de sois extraordinaries," in L'Ami du clergé, 75 (1966), pp. 455-456. [Back]
3 PIUS XII, Address to an International Congress of Anesthesiologists (November 24, 1957), in AAS, 49 (1957), p. 1030. See also PIUS XII, Allocution to the First International Congress of Histopathology, in Human Body, ed. by the Monks of Solesmes (Boston, MA: Pauline Books & Media, 1960), pp. 198-199. [Back]
5 See JOHN PAUL II, Address to two groups of scientists (October 21, 1985), in AAS, 78 (1986), pp. 314-315; JOHN PAUL II, Evangelium Vitae (Boston, MA: Pauline Books & Media, 1995), esp. nn. 64-65. [Back]
6 JOHN PAUL II, Address to World Federation of Catholic Medical Associations and Pontifical Academy for Life Congress on Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas (March 20, 2004), in L'osservatore Romano, 13 (March 30, 2004), p. 5. [Back]
7 Ibid., no. 4, p. 5, emphasis added. [Back]
8 See also an epistemic and essentialist argument by CANADIAN CATHOLIC BIOETHICS INSTITUTE, "Bioethicists Interpret the Papal Speech on Artificial Nutrition and Hydration," in Bioethics Update, 4/1 (2004), pp. 1-4. [Back]
9 CDF, "Declaration on procured Abortion," in AAS, 66 (1974), pp. 730-747. [Back]
10 CDF, "Declaration on Euthanasia," in Origins, 10/10 (1980), pp. 154-157. [Back]
11 CDF, "Declaration on procured Abortion," no. 8, p. 736. [Back]
12 Ibid., no. 9, pp. 736-737.[Back]
13 Ibid., no. 12, pp. 737-738. [Back]
14 CDF, Declaration on Euthanasia, no. 2, p. 154. [Back]
15 Ibid., Declaration on Euthanasia, no. 2, p. 154, emphasis added. See also the Catechism of the Catholic Church, nn. 2278-2279 and JOHN PAUL II, Evangelium Vitae, no. 65. [Back]
16 Ibid., Declaration on Euthanasia, no. 4. See also the Catechism of the Catholic Church, no. 2277; PONTIFICAL COUNCIL FOR PASTORAL ASSISTANCE TO HEALTH CARE WORKERS, The Charter for Health Care Workers (Boston, MA: Pauline Books & Media, 1995), p. 5. [Back]
17 Ibid., Declaration on Euthanasia, no. 4. Here it is also long ethical debate about a question: Is ANH a medical treatment or is it a part of normal care? See for further study, Thomas J. O'DONNELL, S.J., Medicine and Christian Morality, 2nd rev. ed. (Staten Island, NY: Alba House, 1991), pp. 70-73. [Back]
18 THE PONTIFICAL COUNCIL COR UNUM, "Question of Ethics Regarding the fatally Ill and the Dying," in R.E. SMITH, ed., Conserving Human Life (Braintree, MA: Pope John XXIII Medical-Moral Research and Education Centre, 1989), Appendix II, pp. 286-304. [Back]
19 Ibid., Question of Ethics Regarding the fatally Ill and the Dying, no. 2.4.2, p. 291, emphasis added. [Back]
20 Ibid., Question of Ethics Regarding the fatally Ill and the Dying, no. 2.4.3, p. 291, emphasis added. [Back]
21 THE PONTIFICAL ACADEMY OF SCIENCES, "The Artificial Prolongation of Life and the exact determination of the moment of death" (October 21, 1985), in Origins, 15 (1985-1986), p. 415. [Back]
25 NCCB COMMITTEE FOR PRO-LIFE ACTIVITIES, "Nutrition and Hydration: Moral and Pastoral Reflections," in Origins, 21/44 (1992), p. 705. The editor of Origins explains also the history and developing of particular committee. [Back]
26 Ibid., col. 3., p. 706. [Back]
27 Ibid., col. 3., pp. 705-706. [Back]
28 Ibid., col. 1., p. 707. [Back]
29 Ibid., col. 1., p. 707. [Back]
30 Ibid., col. 3., p. 708. [Back]