View Comments      Email Article       Printable Version

Published: July 30, 2008

Even “vegetables” are human

When artificial feeding and hydration are “ordinary,” “proportionate,” and “morally obligatory”

Notes from a Cultural Madhouse

By Christopher Zehnder

Some of comments following the July 25 story California Catholic Daily ran on Janet Rivera, the comotose Sanger woman whose feeding and hydration tubes had been removed and then subsequently restored by court order, focused on the moral necessity of supplying food and hydration to people who are in a comatose or vegetative state. The same questions were raised a few years ago in regard to Terri Schiavo, who had been in a persistent vegetative state for 15 years and had been receiving her sustenance through feeding tubes. Mrs. Schiavo’s husband, Michael, claiming that such measures of nourishment are morally non-obligatory, tried to convince the Florida courts to have his wife’s feeding tubes removed. Michael Schiavo finally prevailed in court. Terri Schiavo died March 29, 2005 of starvation.

One supporter of Michael Schiavo was James Walter, a bioethics professor at Loyola Marymount University in Los Angeles. Walter was one of the signers of an amicus curiae brief in support of Michael Schiavo in the case Jeb Bush v. Michael Schiavo. In 2004 article, co-written with Thomas Shannon, in the National Catholic Reporter, Walters assessed Pope John Paul II's 2004 address in which the pontiff said that persons in a persistent vegetative should not be deprived of nutrition and hydration.

The following is taken from an article I wrote for the Los Angeles Lay Catholic Mission in May 2005, examining Walter’s arguments. I offer it as my contribution to the discussion about the moral necessity of supplying food and hydration to patients in persistent vegetative or similar states.

[The amicus curiae brief Professor Walter signed] makes it sound like the pope's recent statement on the moral necessity of supplying hydration and nutrition to patients in a persistent vegetative state is a departure from Evangelium Vitae and the Declaration on Euthanasia. The statement in question is found in Pope John Paul II's March 20, 2004 address, "To the Participants in the International Congress on 'Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas.'" In this address, the pope affirms that "a man, even if seriously ill or disabled in the exercise of his highest functions, is and always will be a man, and he will never become a 'vegetable' or an 'animal.'" [Emphasis in original.] This being the case, "medical doctors and health-care personnel, society and the Church have moral duties toward these persons from which they cannot exempt themselves without lessening the demands both of professional ethics and human and Christian solidarity."

In particular, the pope said, "the sick person in a vegetative state, awaiting recovery or a natural end, still has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.), and to the prevention of complications related to his confinement to bed." The pope went further "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." [Emphases in original.]

So, for John Paul, since hydration and nourishment are not medical procedures designed to cure an ailment, but are rather ordinary care owed to the human person, they are "ordinary and proportionate" if they achieve their purpose — namely, hydration and nourishment. Presumably, if the patient were unable to digest food, these means would cease to be ordinary and proportionate, and so could be removed. Further, as non-medical procedures, they may not be removed because they do not cure the ailment from which the patient suffers. So, the pope says, "the evaluation of probabilities, founded on waning hopes for recovery when the vegetative state is prolonged beyond a year, cannot ethically justify the cessation or interruption of minimal care for the patient, including nutrition and hydration. Death by starvation or dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission." [Emphasis in original.]

Are these statements a departure from previous Church teaching, as the amicus curiae brief suggests? In the 1980 Declaration on Euthanasia, the Congregation for the Doctrine of the Faith does not directly address the question of the morality of removing hydration and nutrition from a person in a persistent vegetative state. It does say that one is not bound to use extraordinary or "disproportionate" treatments; but Pope John Paul in his address distinguished between treatment and care, saying the latter may never be removed while it achieves its purpose.

The Declaration's definition of euthanasia, however, suggests the pope's further elaboration in his 2004 address. The Declaration states, "by euthanasia is understood an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated." A lethal injection would be an example of an "action ... which of itself or by intention causes death." An omission, it seems, would be the removal of a means by which the life of a person is maintained. One can kill a man by direct measures to end his life — for instance, stabbing him or shooting him — or by removing the necessary means upon which life depends — by starving him or depriving him of water. If directed at a healthy person, these acts of commission and omission would be considered murder. Is it a far stretch for the pope to say that even acts of omission -- removing hydration and nutrition -- would be euthanasia (murder for kindness' sake) when directed at persons in a persistent vegetative state?

In an article co-written with Thomas Shannon and published in the April 16, 2004 National Catholic Reporter, Loyola Marymount's Professor James Walter says the pope's "analysis" of artificial nutrition and hydration in his 2004 address "appear[s] to represent a major reversal of the moral tradition of the Catholic church in assessing whether a particular medical or other intervention is morally obligatory, particularly in the determination of whether this intervention is ordinary or extraordinary treatment." To argue this point, Walter and Shannon deny a major distinction made by the pope: that hydration and nutrition for a patient in the persistent vegetative state is "a natural means of preserving life, not a medical act."

Walter and Shannon offer curious reasons for their denial of the pope's premise. The first is that John Paul uses the terms "ordinary and proportionate" in speaking of these means, "which seems to imply," say Walter and Shannon, "that this kind of intervention is indeed a type of treatment, though an ordinary and morally required one." But do the terms "ordinary and proportionate" only apply to medical interventions? Can not food and drink, for a healthy person, be considered ordinary means for maintaining life? And are they not proportionate -- that is, properly suited -- to their purpose? If they are ordinary and proportionate for a healthy person, why are they not for someone in a persistent vegetative state?

But, Walter and Shannon add, artificially administered nutrition and hydration may be medical acts or treatments because they may lead to complications that require medical treatments. "Such interventions," they say, "can in some instances harm the person because of the possibility of known harmful side effects, such as infections at the site of the insertion of the tube, nausea, vomiting and the possibility of the vomit choking the patient, abdominal swelling, cramping and perhaps diarrhea.... There is a well-established medical literature on the harms and burdens associated with tube feeding. It might be helpful to consult such literature before claiming that such interventions are not a medical treatment."

But do not normal, oral feeding and drinking, sometimes lead to complications that require medical intervention? One can get a bone lodged in his throat, or swallow something that causes a serious allergic reaction or diarrhea, or other harmful effects and burdens. To say eating and drinking may lead or do lead to conditions that require medical aid is not render eating and drinking medical treatment. Or are eating and drinking qualitatively different for persons in a persistent vegetative state than for everyone else?

For Walter and Shannon, it seems, they are, and that because, for a person in a persistent vegetative state, they are administered through a feeding tube. However, they do not argue that a feeding tube is extraordinary and therefore non-obligatory because it replaces the natural activity of swallowing, but because it halts what could be a natural process of dying. "When people begin dying, they frequently stop eating and drinking," write Walter and Shannon. "This is a part of the dying process and interfering with it may in fact interfere with this process and actually harm the patient." But the pope does not argue that one is to use a treatment or even care to halt a natural process of dying, but that one may not, by commission or omission, hasten or bring on death simply because a person is in a persistent vegetative state. The simple fact that, in Walter and Shannon's words, "a person in a persistent vegetative state, assuming a correct diagnosis ... is incapable of orally eating and drinking by his or her self" is not a sufficient cause to allow him or her to starve, according to the pope. Nor does the fact that "the patient will not return to any level of sapient or sentient existence" indicate that the patient is in the process of dying.

The burden of Walter and Shannon's argument rests on the assertion that artificial hydration and nutrition are "medical treatment," though they admit that they do not cure but only "maintain the physiological process" and "prevent death." Thus the necessity, at the onset of Walter and Shannon' s article, to deny the pope's assertion that giving hydration and nutrition to a person in a persistent vegetative state is not a "medical act." If hydration and nutrition are really only normal care, then Walter and Shannon would have to argue that, in some cases, human beings can be denied such care. In other words, they would have to argue that persons in a persistent vegetative state do not deserve the respect paid to conscious persons They would have to argue that people like Terry Schiavo are really only "vegetables," and not human.

A major point made by Walter and Shannon is that the pope misdiagnoses the moral character of the "intervention" in question. "The primary determinant," they say, "of whether the intervention is morally ordinary or extraordinary is not how the intervention -- whether a medical therapy or some other kind of intervention -- is classified. Historically, the determinant has been the effect on the patient. Thus the fact that some intervention is considered a 'natural means' ... as the pope suggests, does not determine the moral or obligatory status of the intervention." But the pope does consider the effect on the patient; he simply denies that, in this case, it is a medical effect. The "administration of food and water," says John Paul, is "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." For the pope, there are cases where food and water can be removed -- cases where they fail to achieve their proper effect, i.e., providing nourishment and alleviation of suffering. They can not be removed because one judges a life is not worth living.

But in speaking of the "effect" of a treatment, Walter and Shannon also refer to burdens it can place on the family of a patient. As they state, the Holy See's Declaration on Euthanasia allows that "one may refuse an intervention from a desire 'not to impose excessive expense on the family or the community.'" But, here, the Declaration is referring to medical treatments or remedies, not normal care. The Declaration goes on to say, "when inevitable death is imminent in spite of the means used, it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted." [Emphasis added.]

Too, in his 2004 address, Pope John Paul II emphasizes that families should not be left to bear the burden of care alone. "It is necessary," the pope says, "above all, to support those families who have had one of their loved ones struck down by this terrible clinical condition. They cannot be left alone with their heavy human, psychological and financial burden. Although the care for these patients is not, in general, particularly costly, society must allot sufficient resources for the care of this sort of frailty, by way of bringing about appropriate, concrete initiatives...."

The pope does not address the question of what should be done when even society can not "allot sufficient resources" for care of people in a persistent vegetative state, though, presumably, he does not enjoin the impossible. But in speaking to those places (such as the United States) where such care can be provided, the pope does insist on the sanctity of all life, on the right of all men, irregardless of wealth, race, religion, or physical ability to have their life respected. "A man, " says the pope, "even if seriously ill or disabled in the exercise of his highest functions, is and always will be a man, and he will never become a 'vegetable' or an 'animal'. Even our brothers and sisters who find themselves in the clinical condition of a 'vegetative state' retain their human dignity in all its fullness. The loving gaze of God the Father continues to fall upon them, acknowledging them as His sons and daughters, especially in need of help." [Emphasis in original.]

© California Catholic Daily 2008. All Rights Reserved.