Human Dignity and the End of Life

In September 2007 the Congregation for the Doctrine of the Faith issued a Response approved by Pope Benedict to answer two questions posed by the U.S. Conference of Catholic Bishops on our moral obligations to patients who exist in what has come to be called a “persistent vegetative state.” The Congregation’s Response and its accompanying Commentary confirm and explain the statements made by Pope John Paul II on March 20, 2004, on the moral obligation to provide food and fluids to P.V.S. patients when they need such assistance to survive. Two recent articles in America, “On Church Teaching and My Father’s Choice,” by John J. Hardt (1/21), and “At the End of Life,” by Thomas A. Shannon (2/18), appear to misunderstand and subsequently misrepresent the substance of church teaching on these difficult but important ethical questions.

Thomas Shannon, in his article, cites the Declaration on Euthanasia of 1980, which spoke of the discretion patients may have to refuse medical treatment that seems to them burdensome, and therefore “extraordinary” or disproportionate. He argues that this judgment by a patient is distinct from a physician’s judgment that a treatment is “medically ordinary” in the sense of being customary or usual. What is “medically ordinary” can be “morally extraordinary.” This is a valid distinction, but there is an aspect of patient care even more basic than the distinction between ordinary and extraordinary medical treatments: the “ordinary care” owed to sick persons because of their human dignity, which the Declaration said should be provided even when certain medical interventions have been withdrawn as useless or overly burdensome. Pope John Paul II and his successor held that food and water, even when their provision may require technical medical assistance, constitute the “basic care” that patients should receive. The value of such medical assistance is not to be judged by its efficacy in curing the patient or improving the patient’s condition. Supplying the basic necessities of life can often require the assistance of others, in the case, for example, of those who are very young or very old, or simply very weak at any age.

In the case of medically stable patients in a “vegetative state,” who may live a long time with continued nourishment but will certainly die of dehydration or starvation without it, the obligation to care for our fellow human beings presents a very direct challenge. Such a patient’s condition should not be characterized as “unstable” or terminal simply because it would become so if the patient were deprived of food and water.

It is true that this obligation to provide basic care can be exhausted when such assistance can no longer fulfill its basic purpose or finality. The U.S. bishops asked the C.D.F. whether food and fluids should be provided “except when they cannot be assimilated by the patient’s body or cannot be administered to the patient without causing significant physical discomfort,” and the congregation’s response recognized the legitimacy of this exception.

When patients are dying and their bodily systems are shutting down at the end of life, medically assisted nourishment can be ineffective and even create additional suffering. This is why physicians did not initiate tube-feeding for Pope John Paul II himself when he was in his final days. The pope’s condition in his final hours was in no way comparable to that of a P.V.S. patient, who can live a long time with assisted feeding.

Thomas Shannon, in his article, confuses the three exceptions recognized in the congregation’s Response and Commentary, and John Hardt finds four such exceptions. The C.D.F. Commentary does speak of a situation where the obligation to provide nutrition and hydration does not apply. This is not really an exception to the norm, but rather the simple recognition that we are never obliged to try to do the impossible. Some parts of the world may be so destitute or undeveloped that they lack the medical resources and skills for the kind of assisted feeding that can occasion difficult moral decisions. John Hardt goes further when he suggests that the C.D.F. Commentary introduces a broader and more subjective category of “burden” that justifies a simple dislike for survival in a helpless state. But that claim has no foundation in the text, is actually contradicted by the Response and raises an additional problem that is discussed below.