Artificial Nutrition and Hydration and the Permanently Unconscious Patient

Artificial Nutrition and Hydration and the Permanently Unconscious Patient: The Catholic Debate

Ronald P. Hamel
James J. Walter
Copyright Date: 2007
Pages: 304
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  • Book Info
    Artificial Nutrition and Hydration and the Permanently Unconscious Patient
    Book Description:

    During the past few decades, high-profile cases like that of Terry Schiavo have fueled the public debate over forgoing or withdrawing artificial nutrition and hydration from patients in a persistent vegetative state (PVS). These cases, whether involving adults or young children, have forced many to begin thinking in a measured and careful way about the moral legitimacy of allowing patients to die. Can families forgo or withdraw artificial hydration and nutrition from their loved ones when no hope of recovery seems possible? Many Catholics know that Catholic moral theology has formulated a well-developed and well-reasoned position on this and other end-of-life issues, one that distinguishes between "ordinary" and "extraordinary" treatment. But recent events have caused uncertainty and confusion and even acrimony among the faithful. In his 2004 allocution, Pope John Paul II proposed that artificial nutrition and hydration is a form of basic care, thus suggesting that the provision of such care to patients neurologically incapable of feeding themselves should be considered a moral obligation. The pope's address, which seemed to have offered a new development to decades of Catholic health care ethics, sparked a contentious debate among the faithful over how best to treat permanently unconscious patients within the tenets of Catholic morality. In this comprehensive and balanced volume, Ronald Hamel and James Walter present twenty-one essays and articles, contributed by physicians, clergy, theologians, and ethicists, to reflect the spectrum of perspectives on the issues that define the Catholic debate. Organized into six parts, each with its own introduction, the essays offer clinical information on PVS and feeding tubes; discussions on the Catholic moral tradition and how it might be changing; ecclesiastical and pastoral statements on forgoing or withdrawing nutrition and hydration; theological and ethical analyses on the issue; commentary on Pope John Paul II's 2004 allocution; and the theological commentary, court decisions, and public policy resulting from the Clarence Herbert and Claire Conroy legal cases. A valuable resource for students and scholars, this teachable volume invites theological dialogue and ethical discussion on one of the most contested issues in the church today.

    eISBN: 978-1-58901-242-4
    Subjects: Health Sciences, Religion

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-x)
  3. Introduction: The State of the Debate
    (pp. 1-6)
    Ronald P. Hamel and James J. Walter

    The debate about forgoing or withdrawing artificial nutrition and hydration, especially regarding patients in a persistent vegetative state, dates back at least to the early 1980s. High-profile cases brought the issue to the fore and to the attention of clinicians, bioethicists, theologians, attorneys, legislators, and the general public: In the 1982 Baby Doe case, an infant with Down syndrome and esophageal atresia was denied artificial nutrition and hydration; in the 1983 Clarence Herbert case, two physicians were charged with murder for discontinuing nutrition and hydration for a patient who had suffered a profound anoxic brain injury; and in the 1983...

  4. PART ONE: Medical Perspectives

    • [PART ONE Introduction]
      (pp. 7-8)

      Good ethics, it is often said, begins with good facts. Unless there is a clear and accurate understanding of the issue at hand in its various dimensions, it is quite likely that moral judgments would be misjudgments or would be correct judgments only by chance. When what is at stake is human life and well-being, especially of vulnerable individuals, every effort should be made to obtain the best possible understanding of relevant factual information before making treatment decisions. Such information is also critical to the possibility of dialogue among those of differing perspectives. If there is not a common understanding...

    • 1 Position of the American Academy of Neurology on Certain Aspects of the Care and Management of the Persistent Vegetative State Patient
      (pp. 9-14)
      American Academy of Neurology

      I. The persistent vegetative state is a form of eyes-open permanent unconsciousness in which the patient has periods of wakefulness and physiological sleep/wake cycles, but at no time is the patient aware of him- or herself or the environment. Neurologically, being awake but unaware is the result of a functioning brain stem and total loss of cerebral cortical functioning.

      A. No voluntary action or behavior of any kind is present. Primitive reflexes and vegetative functions that may be present are either controlled by the brain stem or are so elemental that they require no brain regulation at all.

      Although the...

    • 2 Feeding Tubes: Sorting Out the Issues
      (pp. 15-26)
      Myles N. Sheehan

      The use of feeding tubes, especially in long-term care settings, is a touchy issue in Catholic health care. Decisions about feeding tube use can be difficult for a variety of reasons: complicated clinical situations, strong emotions surrounding these decisions on the part of families and caregivers, and conflicting perceptions of church teaching. Given these circumstances, not all will agree about the use of feeding tubes. But we can achieve much more clarity surrounding the issue than is currently the case.

      Better decision making about the use of feeding tubes for artificial nutrition and hydration can be achieved by three interlocking...

  5. PART TWO: The Catholic Tradition and Historical Perspectives

    • [PART TWO Introduction]
      (pp. 27-28)

      Any discussion of forgoing or withdrawing artificial nutrition and hydration for patients in a persistent vegetative state must ultimately return to the tradition. For almost five hundred years theologians beginning with the Spanish Dominican theologian Francisco de Vitoria (1486–1546) have addressed the moral obligation to preserve one’s life and the limits to that obligation. These discussions have consistently focused on two primary considerations—the duty to preserve life and what is often referred to as the “relative norm.”

      The duty to preserve life is grounded in the Catholic view toward human life. Life is a gift of God, an...

    • 3 Catholic Teaching on Prolonging Life: Setting the Record Straight
      (pp. 29-52)
      Michael R. Panicola

      Recently there has been a lot of confusion among Catholics regarding the Church’s teaching on prolonging life, especially when it comes to prolonging life with medically assisted nutrition and hydration. This was well illustrated in the nationally publicized case of Hugh Finn, a forty-four-year-old former newscaster in Louisville, Kentucky, who in 1995 suffered a ruptured aorta in a car accident near his home.¹ The lack of oxygen to the brain that Finn sustained as a result of the injury left him in a persistent vegetative state (PVS).

      PVS is characterized by the loss of all higher brain functions with either...

    • 4 A History of Ordinary and Extraordinary Means
      (pp. 53-78)
      Donald E. Henke

      The death of Terri Schiavo in Florida on March 31, 2005, brought into high relief many of the central questions concerning the care and treatment of patients in the persistent vegetative state (PVS). At the center of the Catholic discussion of this contentious issue has been whether the provision of food and water is an extraordinary means of conserving life when a patient no longer has any measurable cognitive-affective abilities. Although my own work on the topic of artificially assisted hydration and nutrition (AAHN) is involved with the question of whether such patients are indeed incapable of awareness of themselves...

    • 5 Must We Preserve Life?
      (pp. 79-88)
      Ronald Hamel and Michael Panicola

      Is the removal of a feeding tube that supplies nutrients and fluids, especially in patients in a persistent vegetative state (PVS), simply a means of killing a vulnerable person—a form of euthanasia? Judging from some of the responses to the much-publicized Terri Schiavo case, it seems there are those who think so, including a fair number of Catholics. (Ms. Schiavo, a thirty-nine-year-old Florida resident, suffered severe brain damage after a collapse in 1990 and has been sustained since then by a feeding tube. Her husband has sought the removal of life-sustaining equipment. This is opposed by her parents and...

  6. PART THREE: Ecclesiastical and Pastoral Perspectives

    • [PART THREE Introduction]
      (pp. 89-90)

      Over the past fifty years, the magisterium and various episcopal bodies have addressed the Catholic moral tradition on the duty to preserve life and forgoing life-sustaining treatment. This section offers a sampling of these statements.

      Two of the most important statements are Pope Pius XII’s 1957 address to anesthesiologists and the Congregation for the Doctrine of the Faith’s 1980 Declaration on Euthanasia. Both documents reiterate familiar themes from the theological tradition although the Declaration on Euthanasia breaks some new ground by introducing the terms “proportionate” and “disproportionate” means as alternatives to “ordinary” and “extraordinary” means. Both of these documents solidified...

    • 6 The Prolongation of Life
      (pp. 91-98)
      Pope Pius XII

      Dr. Bruno Haid, chief of the anesthesia section at the surgery clinic of the University of Innsbruck, has submitted to Us three questions on medical morals treating the subject known as “resuscitation” [la réanimation].

      We are pleased, gentlemen, to grant this request, which shows your great awareness of professional duties, and your will to solve in the light of the principles of the Gospel the delicate problems that confront you.

      According to Dr. Haid’s statement, modern anesthesiology deals not only with problems of analgesia and anesthesia properly so-called, but also with those of “resuscitation.” This is the name given in...

    • 7 Declaration on Euthanasia
      (pp. 99-106)
      Sacred Congregation for the Doctrine of the Faith

      The rights and values pertaining to the human person occupy an important place among the questions discussed today. In this regard, the Second Vatican Ecumenical Council solemnly reaffirmed the lofty dignity of the human person, and in a special way his or her right to life. The Council therefore condemned crimes against life “such as any type of murder, genocide, abortion, euthanasia, or willful suicide” (Pastoral Constitution Gaudium et Spes, n. 27).

      More recently, the Sacred Congregation for the Doctrine of the Faith has reminded all the faithful of Catholic teaching on procured abortion.¹ The Congregation now considers it opportune...

    • 8 The Artificial Prolongation of Life
      (pp. 107-108)
      Pontifical Academy of Sciences

      On the invitation of the Pontifical Academy of Sciences, a study group met Oct. 19–21, 1985, to study “the artificial prolongation of life and the exact determination of the moment of death.”

      After having noted the recent progress of the techniques of resuscitation and the immediate and long-term effects of brain damage, the study group discussed the objective criteria of death and of the rules of conduct in the face of a persistent state of apparent death. On the one hand, experiments carried out reveal that brain resistance to the absence of cerebral circulation can permit recoveries otherwise deemed...

    • 9 On Withdrawing Artificial Nutrition and Hydration
      (pp. 109-114)
      Texas Bishops and the Texas Conference of Catholic Health Facilities

      Human life is God’s precious gift to each person. We possess and treasure it as a sacred trust. All persons therefore have a moral responsibility, in accord with their own capacities, roles and personal vocation, to make those decisions and take those necessary steps to preserve and promote their own life and health and that of others. We firmly reiterate the church’s continued condemnation of euthanasia as defined in the Vatican’s 1980 Declaration on Euthanasia

      This responsibility for conserving life and health falls especially upon those persons and institutions directly involved in the healing ministry. Catholic health facilities have a...

    • 10 Nutrition and Hydration: Moral and Pastoral Reflections
      (pp. 115-136)
      National Conference of Catholic Bishops’ Committee for Pro-Life Activities

      Modern medical technology seems to confront us with many questions not faced even a decade ago. Corresponding changes in medical practice have benefited many but have also prompted fears by some that they will be aggressively treated against their will or denied the kind of care that is their due as human persons with inherent dignity. Current debates about life-sustaining treatment suggest that our society’s moral reflection is having difficulty keeping pace with its technological progress.

      A religious view of life has an important contribution to make to these modern debates. Our Catholic tradition has developed a rich body of...

    • 11 Ethical and Religious Directives: Introduction to Part V and Directives 57–58
      (pp. 137-140)
      United States Conference of Catholic Bishops

      Christ’s redemption and saving grace embrace the whole person, especially in his or her illness, suffering, and death.³⁵ The Catholic health care ministry faces the reality of death with the confidence of faith. In the face of death—for many, a time when hope seems lost—the Church witnesses to her belief that God has created each person for eternal life.³⁶

      Above all, as a witness to its faith, a Catholic health care institution will be a community of respect, love, and support to patients or residents and their families as they face the reality of death. What is hardest...

  7. PART FOUR: Ethical and Theological Perspectives

    • [PART FOUR Introduction]
      (pp. 141-142)

      While the preceding sections have discussed the key components of the debate about forgoing or withdrawing artificial nutrition and hydration for persons in a persistent vegetative state and the differing views about them, the present section offers more in-depth theological and ethical analyses of many of these critical and basic assumptions. This cluster of issues, most present from the very beginning of the debate and still unresolved, consists of the following questions

      Is there a moral obligation to preserve human biological life in PVS patients even when there is no hope of recovery of consciousness?

      What counts as burdens and...

    • 12 The PVS Patient and the Forgoing/ Withdrawing of Medical Nutrition and Hydration
      (pp. 143-170)
      Thomas A. Shannon and James J. Walter

      Over the last several decades modern medicine has progressed at a rate that has astonished even its practitioners. Developments in drugs, vaccines, and various technologies have given physicians an incredible amount of success over disease and morbidity as well as allowing them to make dramatic interventions into the body to repair or replace a problematic system or organ. Yet, there are limits we are coming to recognize slowly and only reluctantly. For even many of our best technologies are only halfway technologies, that is, the technology or intervention compensates for a function but cannot cure the underlying pathology or correct...

    • 13 Should Nutrition and Hydration Be Provided to Permanently Unconscious and Other Mentally Disabled Persons?
      (pp. 171-186)
      Germain Grisez

      The title of this article can be understood either as a legal or as an ethical question. I treat it here only insofar as it is an ethical question—that is, a moral issue.¹ But I hope my treatment will contribute to the current debate about what law ought to require in this matter. For, of course, questions about what law should require are, at least in large part, moral questions.

      In its reflection on moral questions, ethics has a task very different from that of legal studies which focus on the making and application of social rules. For ethics...

    • 14 End-of-Life Care Revisited
      (pp. 187-200)
      Daniel P. Sulmasy

      A number of claims made in recent discussions about Catholic teaching and the use of life-sustaining treatments raise important and very serious theological, philosophical, and medical questions that have received almost no direct attention or examination.

      Some recent forms of argument seem to deviate from established, traditional forms of Catholic argument. Yet the nature and extent of these deviations from tradition have not been apparent to most commentators. Some recent claims have been based upon oversimplified understandings of clinical and economic reality. Still other claims appear to be based upon novel philosophies of medicine that have not been made explicit....

  8. PART FIVE: John Paul II’s Papal Allocution and Responses

    • [PART FIVE Introduction]
      (pp. 201-202)

      On March 20, 2004, Pope John Paul II addressed participants in an international congress at the Vatican on “Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas.” The pope’s speech, “Care for Patients in a ‘Permanent’ Vegetative State,” set off a vigorous debate, especially in the United States, regarding its authority as well as how the speech should be interpreted, and it also intensified the debate about the moral justifiability of forgoing or withdrawing artificial nutrition and hydration for patients in PVS. The papal allocution seems to have affirmed the position that began to emerge in the early 1980s,...

    • 15 Care for Patients in a “Permanent” Vegetative State
      (pp. 203-208)
      Pope John Paul II

      1. I cordially greet all of you who took part in the International Congress: “Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas.” I wish to extend a special greeting to Bishop Elio Sgreccia, vice president of the Pontifical Academy for Life, and to Professor Gian Luigi Gigli, president of the International Federation of Catholic Medical Associations and selfless champion of the fundamental value of life, who has kindly expressed your shared feelings.

      This important congress, organized jointly by the Pontifical Academy for Life and the International Federation of Catholic Medical Associations, is dealing with a very significant issue:...

    • 16 John Paul II on the “Vegetative State”
      (pp. 209-214)
      Richard M. Doerflinger

      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...

    • 17 Medically Assisted Nutrition and Hydration: A Contribution to the Dialogue
      (pp. 215-222)
      Mark Repenshek and John Paul Slosar

      The Address to Participants in the International Congress on “Life-Sustaining Treatments and the Vegetative State: Scientific Advances and Ethical Dilemmas,” promulgated in March of this year by Pope John Paul II, has become a source of considerable controversy, partly due to the theological and clinical complexity of this issue, and partly because of how it has been portrayed in the popular media.¹ In light of this controversy, many Catholics, as well as Catholic health systems, are re-examining the half-millennium-old tradition of Catholic moral teaching regarding the obligation to use particular means of sustaining human life.² In this essay, we seek...

    • 18 Assisted Nutrition and Hydration and the Catholic Tradition
      (pp. 223-236)
      Thomas A. Shannon and James J. Walter

      The Terri Schiavo case in Florida focused attention on a variety of issues related to the end of life: who is the decision maker, the status of advanced directives, the role of family members with respect to married adult children, and issues related to the removal of life support systems, particularly assisted nutrition and hydration. Terri Schiavo is now linked to two other young women who played a critical role in helping us to think through ethical issues at the end of life. Karen Ann Quinlan and her family raised the issue of the removal of a ventilator. In her...

    • 19 Reflections on the Papal Allocution Concerning Care for Persistent Vegetative State Patients
      (pp. 237-254)
      Kevin O’Rourke

      Recently, Pope John Paul II issued a statement in regard to the care of persons in the persistent vegetative state (PVS) (2004). The statement was received with dismay by many people inside and outside the Catholic healthcare ministry (see O’Brien, 2004; Shannon and Walter, 2004). In sum, the Holy Father stated that artificial nutrition and hydration (AHN) was not medical care, but rather comfort care, and in principle should be maintained even if there is no hope that the patient will recover from the debilitated condition of PVS. He also maintained that a patient in PVS remains a person in...

  9. PART SIX: Legal and Public Policy Perspectives

    • [PART SIX Introduction]
      (pp. 255-256)

      The debate about forgoing or withdrawing artificial nutrition and hydration is not only theological in nature, it also has public policy dimensions, and the debate has taken place in numerous courts and legislatures across the country. Among the more important legal cases are those concerning Clarence Herbert (Barber v. Superior Court of Los Angeles County, 1983), Claire Conroy (In re Conroy, 1985), Paul Brophy (Brophy v. New Eng. Sinai Hosp., Inc., 1986), Nancy Jobes (In re Jobes, 1987), Marcia Gray (Gray v. Romeo, 1988), Mary O’Connor (In re O’Connor, 1988), Carol McConnell (McConnell v. Beverly Enterprises, 1989), Nancy Cruzan (Cruzan...

    • 20 The Clarence Herbert Case: Was Withdrawal of Treatment Justified?
      (pp. 257-264)
      John R. Connery

      Clarence Herbert, age fifty-five, was admitted to the Kaiser Permanente Hospital in Harbor City, California, on Aug. 25, 1981, for routine closure of an ileostomy. In the recovery room after the surgery on August 26 he suffered respiratory collapse, which one doctor believed was caused by cardiac arrest. It is not clear how much time elapsed before respiration was restored artificially through a respirator, but the anoxia resulted in severe brain damage. According to the testimony of the nurses and the medical board, the patient was in severe or deep—perhaps irreversible—coma.

      The Wayne County medical examiner testified to...

    • 21 Caring or Starving? The Case of Claire Conroy
      (pp. 265-274)
      Richard A. McCormick

      Claire Conroy was an eighty-four-year-old nursing home resident. She suffered from irreversible physical and mental impairments including arteriosclerotic heart disease, diabetes, and hypertension. She could neither speak nor swallow and was fed by a nasogastric tube. Her movements were very limited though she could smile or moan in response to some stimuli. She was restricted to a semifetal position and lacked control of her excretory functions. Thomas C. Whittemore, Miss Conroy’s nephew and guardian, requested that the nasogastric tube be removed from his awake but severely demented aunt. The application was opposed by Miss Conroy’s guardian “ad litem” (for purposes...

  10. Permissions
    (pp. 275-276)
  11. Contributors
    (pp. 277-278)
  12. Index
    (pp. 279-294)