Saturday, September 15, 2007

“Responses to Certain Questions Concerning Artificial Nutrition and Hydration”

On August 1, 2007, The Congregation for the Doctrine of the Faith issued responses to two questions posed by Bishop William Skylstad on July 11, 2005, then-President of the United States Conference of Catholic Bishops, concerning the 2004 address of Pope John Paul II, “Life-Sustaining Treatments and the Vegetative State: Scientific Progress and Ethical Dilemmas.” Included was a commentary explaining the reasoning and implications of the responses. (click here to read the text of the document).

The responses were intended to settle certain questions that have arisen over the meaning and proper interpretation of John Paul II’s 2004 address. The first response affirms that the provision of food and water is “an ordinary and proportionate means of preserving life” and therefore obligatory so long as it fulfills it purpose, “which is the hydration and nutrition of the patient.” In its response, the CDF does not single out any class of persons, but reaffirms the general teaching of John Paul II that the provision of food and water is “in principle” obligatory for all patients, although the commentary does later list some cases in which this rule does not apply. The second response affirms that one may not remove the artificial provision of food and water from a patient simply because a physician has concluded with certainty that the patient will never regain consciousness. The loss of consciousness is not a sufficient reason to deprive a patient of ordinary care.

The responses provide a clear rejection of the claim of certain theologians that the provision of food and water for patients in the persistent vegetative state is not morally obligatory. Nutrition and hydration are to be considered ordinary care, not an extraordinary means of preserving life.

We would note that it is unusual for the CDF to provide a commentary to its own responses. Typically, a Vatican reply to a “dubium” consists of a short response and that is all. The commentary is left to others. In this case, however, the CDF appended a very thorough explanation of its position that was evidently meant to ensure that there would be no occasion for theological misunderstanding.

A Change in Catholic Tradition?

Whether the provision of food and water for patients in the persistent vegetative state is morally obligatory has been a controverted question within the Catholic Church for several decades. The 2004 statement of John Paul II, “Life-Sustaining Treatments and the Vegetative State,” was meant to provide some resolution to this question, but it received a mixed response from certain theologians in the United States. Of particular note was the claim that John Paul II had broken with 200 years of Catholic tradition and rejected the teaching of Pope Pius XII on when to forgo extraordinary means of treatment. The CDF responses and commentary address these concerns.

The commentary takes pains to note that John Paul II’s address stands in conformity with previous tradition and is not, in any way, an innovation or an abandonment of previous teaching. The commentary reviews a series of high-level statements from Vatican sources all tending toward the same conclusion on the necessity of providing nutrition and hydration to patients in the vegetative state, including the CDF’s Declaration on Euthanasia (May 5, 1980), the Pontifical Council Cor Unum’s “Some Ethical Questions Relating to the Gravely Ill and the Dying (June 27, 1981), an address of John Paul II to the participants of an international forum on leukemia (November 15, 1985), the Charter for Health Care Workers issued by the Pontifical Council for Pastoral Assistance (1995), and an address of John Paul II to bishops of the United States on their ad limina visit to Rome (October 2, 1998). This review of previous statements speaks to the claim of those who have said John Paul II’s address was completely unexpected and without precedent. The commentary notes that the Pope himself made reference to many of these same documents in his address “Life-Sustaining Treatments and the Vegetative State.”

Of greater significance is that the commentary responds to the claim that John Paul II and Pius XII stand in opposition to each other over the question of whether food and water should be provided to patients in a persistent vegetative state. The commentary acknowledges that the address of Pius XII to a Congress on Anesthesiology, “The Prolongation of Life” (November 24, 1957), is often cited in defense of the view that nutrition and hydration may be taken away from these patients; however, it points out that this is clearly a misreading of the text. Pius was addressing the question of resuscitation in those who had suffered a serious illness and were in the process of dying or already dead. Patients in a vegetative state are not dying. They “breathe spontaneously, digest food naturally, carry on other metabolic functions, and are in a stable situation.” When food and water are removed from these patients, “the cause of their death will be neither an illness nor the ‘vegetative state’ itself, but solely starvation and dehydration.”

The cases under discussion by Pius XII and John Paul II differ. One concerns the prolongation of life through possibly extraordinary means in a patient who has suffered a life-ending illness; the other concerns the preservation of life through ordinary means in a patient who is in a seriously debilitated but stable condition (not dying). Providing food and water to those who are in a permanently unconscious state is not an attempt to effect a cure of their disability, but “to keep the patient from dying of starvation and dehydration.”

Some Exceptions to the Rule

The commentary points out that the CDF recognizes certain exceptions to this rule. In places where medical science is not advanced, and the provision of food and water by artificial means is not possible, there is no moral obligation. The same is true of cases in which food and water are not being assimilated by the body because of disease. In rare cases, it is also possible that nutrition and hydration will be excessively burdensome for a patient, for example, when their administration by tube causes medical complications.