NCBC: Statement of The NCBC on Pope John Paul II's Address on Nutrition and Hydration For Patients In PVS

STATEMENT OF THE NCBC ON POPE JOHN PAUL II'S ADDRESS
ON NUTRITION AND HYDRATION FOR PATIENTS IN PVS
April 23, 2004

Click here to read the Pope’s original Address of March 20, 2004

The ethicists of the National Catholic Bioethics Center (NCBC) have begun a careful examination of Pope John Paul II's recent allocution on life sustaining measures and patients in a persistent vegetative state which is a welcome clarification of Catholic thinking on one of the most vexing and controversial issues in health care.

The pope did not say anything new in his allocution. There is no change in Catholic teaching. Indeed, in paragraph four of the allocution there are references to three earlier Church documents. The Pope's words correct a serious misunderstanding about the circumstances in which nutrition and hydration could be removed from a patient in a persistent vegetative state. The removal of food and water should never be done with the intention of causing the death of the patient. Removal of food and water is permissible in the case of a patient in the vegetative state only when their provision can no longer attain nourishment.

This statement has implications not only for patients in pvs but for all patients who receive or may receive food and water. Many advance directives, which Catholics formerly signed in good faith, and which require the removal of food and water in cases of a persistent vegetative state, may have to be reconsidered.

The words of the Holy Father should settle three related debates among Catholic moralists:

When dealing with pvs patients, some had contended that the presumption should be not to provide nutrition and hydration artificially [ANH] whereas others insisted that the presumption must be to provide artificial nutrition and hydration, even when delivered artificially. The pope clearly decides in favor of the latter.
The second point of clarification was whether artificial nutrition and hydration is care or treatment? The pope is clear: he considers it care. Its purpose is nourishment.
Points one and two show that in general the provision of nutrition and hydration to the patient in the vegetative state is proportionate and morally obligatory, but that in a particular case nutrition and hydration may be extraordinary and disproportionate, and, therefore, morally optional.

The Pope has also rejected the use of the 'quality of life' standard as the sole principle for medical decision-making on behalf of patients in the vegetative state. He has reaffirmed the complete humanity and dignity of these persons.

Since the pope has a global audience, we may assume that he is also addressing the situation in the Netherlands where euthanasia is now legal. The withdrawal of nutrition and hydration with the intent of killing the patient is euthanasia. The same holds true obviously for an intentional overdose of pain medication.

Since there is no departure from tradition in the Holy Father's remarks, the customary moral categories used in Catholic health care still hold. The pope has articulated a general principle for providing nutrition and hydration to patients, including those in a persistent vegetative state. The allocution should be interpreted to allow for prudential case-specific judgments.

While the pope has settled some debates among Catholics, there are issues he did not address such as the ethical significance of the modes of delivery of ANH, types of coma, the significance of the imminence of death, and who should bear the costs of the continued provision of ANH. These issues will continue to form the basis for reflection by ethicists and theologians applying the Pope's recent articulation of Catholic principles.

While this important discussion goes on, the Holy Father in his allocution of March 20, 2004 has reminded all who are involved in the healing professions that health care must be inclusive rather than exclusive. In this regard, note the lone scriptural citation in the allocution: "Amen, I say to you, whatever you did for one of these least brothers of mine, you did for me" (Mt 25: 40).

Further Commentary by
Peter J. Cataldo, Ph.D.
Director of Research
NCBC

April 8, 2004

The comments below are restricted to the third paragraph of section 4 in the allocution:

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 as 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. [“Address of John Paul II to the Participants in the International Congress on ‘Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas’”]

In this critical paragraph the Holy Father is both articulating a general moral principle about the administration of water and food and applying that principle to the vegetative state patient. There are several concepts and distinctions within the Pope’s articulation of the principle which should be identified.

The principle presumes that the moral good to be sought is the preservation of life.
The means by which this good is fulfilled must be distinguished from the particular acts that implement the means.
The “administration of water and food” refers to the reception of water and food with the assistance of another person or extrinsic source. This is one natural means by which the good of preserving life is achieved.
The mention of “artificial means” refers to the various sorts of medical acts by which the reception of water and food to fulfill the good of preserving life is accomplished.
Thus, one natural means of achieving the end of preserving life is receiving water and food, and this means may be completed by medical acts (or by nonmedical acts).
These distinctions do not preclude a prudential judgment in a particular case that the administration of water and food is extraordinary and disproportionate (as will be shown below). In particular, the distinction between natural means and medical acts indicates that a proper finality or end of administering water and food is nourishment (a “natural means” of preserving life), not that the administration of water and food cannot be disproportionate in particular cases.

The administration of water and food is said to be “in principle, ordinary and proportionate.” There are several additional key concepts and distinctions relevant to this point.

Prescinding from the circumstances of any particular patient’s condition, and considering only the essence of water and food as preserving life, their administration is per se reasonable or proportionate, whereas a toxic substance would not be a per se proportionate means of preserving life.
It is on this level of general principle that the administration of water and food is per se morally obligatory. Consistent with this fact there is a presumption in favor of administering water and food to the patient in a vegetative state.
In some cases the “proper finality” of administering water and food may include helping in the cure of disease as well as providing nourishment. In other cases, such as patients in the vegetative state, the proper finality may be restricted to nourishment. In either case suffering is alleviated.
The administration of water and food is per se ordinary and proportionate, but this does not preclude that per accidens and in the particular case it may be extraordinary and disproportionate. In such a case the presumption in favor of administering water and food would no longer hold and a proportionate means of preserving life would be obligatory. This latter case must be contradistinguished from knowingly and willingly causing the death of a person by withdrawing water and food which would otherwise be beneficial.
A practical consequence of the allocution is that some patients for whom the administration of water and food is ordinary and proportionate may have to be transferred out of Catholic health care facilities due to a conflict with the wishes of these patients.

Click here to read the Pope’s original Address of March 20, 2004