June 26, 2009 05:03 PM
This issue of Ethics & Medics offers two replies to the recent statement of the Consortium of Jesuit Bioethics Programs, the first reply by the ethicists of The National Catholic Bioethics Center, and the second by a distinguished group of Catholic scholars interested in issues of bioethics. At stake is whether the Ethical and Religious Directives for Catholic Health Care Services, authored by the United States Conference of Catholic Bishops, should be revised in light of recent statements from the Vatican on the provision of food and water for patients in a persistent vegetative state. These changes would affect the end of the introduction to Part V of the Directives, “Issues in Care for the Dying,” and directive 58, concerning the administration of medically assisted food and water. The members of the Jesuit Consortium have argued against any revision.—Ed.
The Consortium of Jesuit Bioethics Programs, a group of seven bioethics programs at Jesuit universities in the United States, has published a critique of papal teaching on providing food and water to patients in a persistent vegetative state (PVS). Their article “Undue Burden? The Vatican and Artificial Nutrition and Hydration,” was printed in the February 13, 2009, issue of Commonweal.
In the article, they make a wide range of claims about the March 2004 address of John Paul II on life-sustaining treatments and the vegetative state, and about the August 2007 response from the Congregation for the Doctrine of the Faith (CDF) to questions from the U.S. Conference of Catholic Bishops concerning artificial nutrition and hydration (ANH).(1) The Consortium claims, for example, that the Vatican now mandates percutaneous endoscopic gastrostomy (PEG) tubes for a broad class of patients; that many patients will be deprived of the benefits of hand-feeding; that Church teaching will impose heavy financial burdens on patients and their families; and most significantly, that the Vatican has infringed on patient autonomy.
In this brief response, we show that these claims are false and that the authors of the Consortium have not properly understood the documents in question.
General Observation
The purpose of these two Vatican documents was to address the moral obligation to provide food and water to patients in a PVS. These are patients who cannot decide such matters for themselves and so must rely on loved ones and health care workers to make the proper decisions for them. Given the tendency of some to argue that patients in a PVS should be deprived of food and water, it was not surprising that the Vatican would wish to speak to the moral aspects of this issue.
The provision of food and water to patients who are in a vegetative state and who are otherwise healthy is morally obligatory, but this does not mean that ANH is mandatory for all patients who are having difficulty eating and drinking. Although it should be expected that other patients who are not in a PVS but suffer similar cognitive disabilities should also receive food and water as needed, the Consortium’s claim that John Paul II’s address “defines ANH as ordinary and obligatory” (Commonweal, 14) is simply false.
Is Tube-Feeding Now Preferable?
First of all, and most importantly, the 2004 address and the 2007 response both allow for the administration of food and water by either natural or artificial means. When the U.S. Conference of Catholic Bishops inquired whether the administration of food and water “by either natural or artificial means” was morally obligatory for patients in a PVS, the CDF’s response stated that the provision of food and water is necessary “even by artificial means.” The phrase “even by artificial means” presupposes that natural means of providing food and water are preferable whenever they are possible. The Consortium, however, asserts that the Vatican, in these two documents, holds that artificial means of feeding are required not only for patients in a PVS, but for all terminal patients whatsoever.
In many cases, patients can still feed themselves at the end of life. Those who cannot may still be effectively hand-fed. Because tube-feeding remains a measure of last resort, hand-feeding may continue for some time even if it does not provide the patient with full nutritional requirements. Among those who cannot be hand-fed and who are near death, a simple intravenous line often proves to be the best means of providing comfort. The Vatican documents do not declare tube-feeding to be mandatory for all patients at the end of life, nor do they abandon the commonsense view that the simplest and most humane way of feeding patients is the best.
Given the false premise that the Vatican now “defines ANH as ordinary and obligatory,” various absurd conclusions follow. One is that many patients will be deprived of the benefits of hand-feeding under Church teaching.
The authors ask us to believe that the Church no longer supports the hand-feeding of patients. The authors state, “Although hand feeding takes more time, we urge families and health-care workers to provide hand-feeding as an alternative to ANH whenever nutritional needs can be met equally well in this manner” (14). This is proposed as if it were a course of action that is preferable to what is advocated in the Vatican documents, but in fact, there is nothing in the 2004 address or the 2007 response that suggests opposition to hand-feeding. When faced with the choice of natural or artificial means, the natural means of hand-feeding is preferable in almost every case where it is possible.
The Consortium also states that an accurate reading of recent Church teaching requires patients with end-stage Alzheimer’s to be tube-fed, even though scientific evidence suggests that such patients would not live longer by using this method than if hand-fed. We would only note that if it is true that patients with Alzheimer’s do not live any longer when they are tube-fed instead of hand-fed, and if tube-feeding offers no other benefits or advantages to such patients, then it should be obvious that they ought to be hand-fed when that is possible. The claim that the Church would object to such an approach, and demand that patients be placed on tube-feeding even though it would provide no benefit, is disingenuous.
Are There Enormous New Costs?
Yet another misleading claim is that a great many families, now compelled to use tube-feeding, will be burdened with enormous costs. Although the estimated annual cost of caring for a loved one on a PEG tube at home ($9,000 to $25,000 a year) and in a professional setting ($60,000 a year) can seem high, this problem affects any patient who has suffered an incapacitating medical event, whether it requires tube-feeding or not. The costs arise not so much from the tube-feeding itself (which is generally inexpensive and covered by insurance), but from the custodial care required to meet the patient’s basic needs.
In a society as wealthy as ours, it is reasonable to expect that these basic human needs should be met. As already noted, the Church allows for the provision of food and water through either natural or artificial means; it does not mandate the artificial over the natural. In the vast majority of cases, the natural means of feeding will be appropriate. At other times, an intravenous line will be sufficient. If there are genuine cases of fiscal hardship because of the need for extended custodial care, they will be what the CDF calls physical impossibilities, and thus not obligatory.(2) But such cases would not be expected to occur with any great frequency in the United States. We should change the law on medical reimbursements, if that is necessary, rather than abandon these patients.
The Consortium’s concern about the high costs of tube-feeding is inconsistent when we compare it to what they say about hand-feeding. The Consortium states that we should prefer hand-feeding, whenever possible, even though it is more expensive than tube-feeding. If the authors object to tube-feeding because of its attendant custodial expense, what prompts them to favor a method that is even more expensive?
Has Patient Autonomy Been Infringed?
Finally, we come to what, according to the Consortium, is the most egregious error in recent Church teaching: Patients who previously could refuse burdensome interventions are no longer allowed to do so because “the papal address defines ANH as ordinary and obligatory—regardless of the patient’s judgment” (14). We have already pointed out that the first half of this claim is false. Church teaching does not require ANH, but it does require that patients receive food and water by either natural or artificial means.
In connection with this error, the Consortium states that even “though John Paul II explicitly maintains that providing ANH is not a medical act, the reality is that within the fields of medicine and law, the practice generally is viewed as a medical treatment” (14). John Paul II certainly understood that the insertion of a PEG tube is a medical procedure. The suggestion that he was uninformed on this point is unfair. In his address, the Holy Father did not say that the provision of ANH “is not a medical act”; he said that the provision of food and water is not a medical act. (3) Again, there is a great deal of difference between these two statements. The provision of food and water is a part of ordinary care.
If medical treatment concerns the cure or amelioration of a pathological condition, then food and water are not medical treatments. They do not cure or ameliorate hunger and thirst; they satisfy these desires, which are natural to the human condition. We will never be without these needs. Food and water are like blankets, clean surroundings, physical movement, and human contact—they form the basic elements of care that are necessary for all those who suffer illness.
Every patient has the right to direct his or her own course of treatment and care. There are no new restrictions on this freedom. The CDF’s commentary on their response specifically states that anyone who experiences “excessive physical discomfort” may abandon even food and water if it becomes too “burdensome.”(4) This will be a decision of the patient, or of the designated health care proxy, but given modern methods of palliative care, the experience of this kind of suffering typically can be resolved or significantly minimized. The implication that Church documents sanction the harming of patients through the imposition of misguided and unwanted “care” is mistaken. The best interest of the patient always takes precedence in Church teaching on medical ethics.
Care is a moral duty that we owe to every patient—indeed, to every human being, whether sick or healthy. Unlike treatment, there can be no “extraordinary” care. If care does not fulfill its purpose of either preserving life or providing comfort, then its use is unjustifiable and must be discontinued.
Most patients will remain the best judge of what truly constitutes care in their own case, but this freedom obviously cannot include the decision to commit suicide through an arbitrary refusal of food and water. Patients who are in a debilitated cognitive state cannot direct their own care, not because the Vatican has taken that decision away from them, but because they are incapacitated. Those who care for these patients are similarly constrained from bringing about their deaths through the arbitrary removal of food and water.
Not a Helpful Intervention
The Consortium’s misunderstanding of John Paul II’s address and the CDF’s response is not helpful in providing guidance to those charged with establishing policies and protocols for Catholic health care ministry. It is particularly unfortunate that their interpretation of the documents in question leads to the appearance of a division between magisterial teaching and the provision of sound health care.
The Ethicists of The National Catholic Bioethics Center
John M. Haas, Ph.D., S.T.L., K.M.
Rev. Alfred Cioffi, S.T.D., Ph.D.
Edward J. Furton, M.A., Ph.D.
Marie Hilliard, J.C.L., Ph.D., R.N.
Stephen Napier, Ph.D.
Rev. Tadeusz Pacholczyk, Ph.D.
--------------------------------------------------------------------------------
1. John Paul II, Address to the participants in the international congress on “Life-Sustaining Treatments and the Vegetative State: Scientific Advances and Ethical Dilemmas” (March 20, 2004); and Congregation for the Doctrine of the Faith, “Responses to Certain Questions of the USCCB concerning Artificial Nutrition and Hydration” (August 1, 2007), reprinted in Ethics & Medics 32.11 (November 2007): 1–3.
2. CDF, “Responses to Certain Questions,” 3.
3. “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 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.”
4. CDF, Commentary on “Responses to Certain Questions of the USCCB Concerning Artificial Nutrition and Hydration” (August 2007), reprinted in National Catholic Bioethics Quarterly 8.1 (Spring 2008): 123–127.
