Responses to certain questions
September 14, 2007 by Amy
Today, the CDF released a few “responses to certain questions” related to end-of-life care.
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.
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The Supreme Pontiff Benedict XVI, at the Audience granted to the undersigned Cardinal Prefect of the Congregation for the Doctrine of the Faith, approved these Responses, adopted in the Ordinary Session of the Congregation, and ordered their publication.
Rome, from the Offices of the Congregation for the Doctrine of the Faith, August 1, 2007.
The Congregation for the Doctrine of the Faith has formulated responses to questions presented by His Excellency the Most Reverend William S. Skylstad, President of the United States Conference of Catholic Bishops, in a letter of July 11, 2005, regarding the nutrition and hydration of patients in the condition commonly called a “vegetative state”. The object of the questions was whether the nutrition and hydration of such patients, especially if provided by artificial means, would constitute an excessively heavy burden for the patients, for their relatives, or for the health-care system, to the point where it could be considered, also in the light of the moral teaching of the Church, a means that is extraordinary or disproportionate and therefore not morally obligatory.
snip
Therefore, the Responses now given by the Congregation for the Doctrine of the Faith continue the direction of the documents of the Holy See cited above, and in particular the Address of John Paul II of March 20, 2004. The basic points are two. It is stated, first of all, that the provision of water and food, even by artificial means, is in principle an ordinary and proportionate means of preserving life for patients in a “vegetative state”: “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”. It is made clear, secondly, that this ordinary means of sustaining life is to be provided also to those in a “permanent vegetative state”, since these are persons with their fundamental human dignity.
When stating that the administration of food and water is morally obligatory in principle, the Congregation for the Doctrine of the Faith does not exclude the possibility that, in very remote places or in situations of extreme poverty, the artificial provision of food and water may be physically impossible, and then ad impossibilia nemo tenetur. However, the obligation to offer the minimal treatments that are available remains in place, as well as that of obtaining, if possible, the means necessary for an adequate support of life. Nor is the possibility excluded that, due to emerging complications, a patient may be unable to assimilate food and liquids, so that their provision becomes altogether useless. Finally, the possibility is not absolutely excluded that, in some rare cases, artificial nourishment and hydration may be excessively burdensome for the patient or may cause significant physical discomfort, for example resulting from complications in the use of the means employed.
These exceptional cases, however, take nothing away from the general ethical criterion, according to which the provision of water and food, even by artificial means, always represents a natural means for preserving life, and is not a therapeutic treatment. Its use should therefore be considered ordinary and proportionate, even when the “vegetative state” is prolonged.
Thank you, Catholic Christians, for the gift of the Magisterium to the Body of Christ. This is getting to be a far too easily disputed point among Evangelical Christians, in the face of strong, persistent movement on the part of the medical establishment and administrators to call feeding tubes and fluid IVs “heroic and/or unnecessary treatment” and “do the right thing for your loved one.” For every hard case of extended suffering in deep dementia or utter unconsciousness that seems to justify hastening death deliberately by withholding food and fluids are myriad cases of families that just want to Get It Over With.
Thank you, thank you.
End of Life Decision making is not really as cut and dried as this. I have shared in many such deliberations over many years in various settings.This ruling will force the medical team and the family in the future,to think very long and hard before initiating any course of action that could lead to this stand-off. The complexities of modern medicine are legendary in their ability to prolong life.. How long is too long?How should futility be addressed? “No greater love than this…that a man lay down his life for a friend.” Will people be allowed to make a Living Will that accepts hydration and nutrition, but draws the line at becoming an inert, passive processor of nutrition? We will have to create a new type of health care facility to house such cases because it is no simple matter to care for these patients. There are many challenges in routing the formula, bathing, toileting and positioning them. It is not a job for the faint-hearted.
It would be interesting to know how much time B16 and Levada have spent in the company of such total care patients. Also there were decisions made during the dying of JP2 when judgments were made to discontinue futile and possibly harmful care measures.
Tom certainly brings up a point about the ability of the medical world to “prolong” life. How does one deal with the fact that such treatment does use resources and may thereby deny others treatment that is needed to continue living? Will there come a time when only the rich can be treated “morally” while the poor are discarded?
I also note the assumption that the poor are only found in the far corners of the world. I would think that one could also find the poor in the slums of New York City and Los Angels, in the areas where migrant laborers live, or even in some countryside areas. Here in America we are already unwilling to bear the cost of treating illegal immigrants, much less keeping them alive in a veggative state.
In the end, I am somewhat suspicious of morality based on the ability to pay money.
Mike L
My husband works in a facility which provides hospice care to dementia patients, many of whom one might consider only a step above PVS. In the context of his work, we have discussed these issues frequently. In this facility, feeding tubes used to be common, because they save staff time. It is a lengthy process to feed them — as it would be for those in PVS. Nevertheless, a successful effort was made to initiate direct feeding, even though it was time and labor intensive. Sometimes relatives are trained to help. But the task really comes down to our willingness to provide care for those who cannot care for themselves. Who would not feed an infant or toddler, simply because it is time intensive? Why are our needy elderly or injured in a different category, Tom Kelty? One of the issues in Terry Schiavo’s case was that her husband would not allow anyone to attempt direct feeding, even though the nursing home staff was trained, and her parents were willing to be trained, to perform this service for her.
Unfortunately the extreme elderly in this situation may well die from bed sores and the infections that can stem from them and few nurses will look for bed sores recessed in the anal area where infections are most likely to happen. And few staff will move the elderly every two hours on angled foam cushions so as to avoid bed sores. I have personal experience of three very good looking institutions doing a bad job in this area with family. I’m sure there are nun nurses on this planet who would constantly check such things but outside of them, each part of the country has better or lesser records in this area. I believe Amy’s area of the country has a good but certainly not perfect record….but she is safer than I and my family if she or we reach the very elderly stage. It taught me not to fear leaving this world earlier than that stage. Indeed I several times asked it in prayer after that experience.
I’ve posted on this topic before on a previous post, but still think that my own family’s experience with elderly end-of-life decisions could be useful to others.
Tom said-
“This ruling will force the medical team and the family in the future,to think very long and hard before initiating any course of action that could lead to this stand-off.”
This decision should, of course, be thought long and hard about! And no, it is no fun having to bathe someone in bed or make sure that they don’t get bedsores or monitor those who are doing those things for you. It’s no fun swabbing your relative’s mouth out, or doing myriad other deeds for them. It is very taxing for other family members, not just the one who is ill. But these are the crosses we offer up out of love.
“Will people be allowed to make a Living Will that accepts hydration and nutrition, but draws the line at becoming an inert, passive processor of nutrition?”
What is the distinction you are making here? I am not sure. Either way, the person is a living person who needs these fundamentals in order to survive, however long that survival might be. What I do know is that, especially with wasting or “failure to thrive” situations (as we were once in), intentional deprivation of food or water will most likely kill the patient. And that action is, to put it as simply and bluntly as possible, on the consciences of the family and doctors who advise them.
Hopefully, when someone’s life comes down to these sorts of decisions- his or her family will be strong enough to listen, through their heartache, to good counsel. Sometimes it seems so easy to give in, especially when you’re already hurting.