The Pontifical Academy for Life on Artificial Nutrition and Hydration
A Change in Catholic Teaching?
In early July, the Pontifical Academy for Life (PAL) published a short book titled The Little Lexicon for the End of Life (Piccolo lessico del fine-vita). The book is a summary of Catholic teaching on the pastoral care of patients at the end of life and on the ethical issues that arise in the medical treatment of these patients. The introduction to the book, written by Vincenzo Paglia, the President of the PAL, explains that one purpose of the book is to provide clarity on Church teaching in a context where terms are sometimes used in conflicting ways or when Catholic teaching is sometimes presented in a simplistic or even erroneous way.
Despite this intention, the book has come under scrutiny in recent weeks over what it has to say on the topic of artificial nutrition and hydration (ANH). For example, on August 9, Elise Ann Allen, writing for Crux Now, reported that the book “loosens” the Church’s stance on providing ANH for patients in a “permanent vegetative state.” A few days later, the Catholic ethicist Charles Camosy argued that the book “raise[s] real questions about its understanding of and alignment with previous Church teaching documents” on the question of ANH, among other issues. On the other hand, the Catholic News Agency cites Fr. Tad Pacholczyk, an ethicist at the conservative National Catholic Bioethics Center in Philadelphia, who claimed that the book’s treatment of ANH is in line with earlier magisterial teaching.
Before weighing in on the question myself, I think it’s worth pointing out that the book is not intended as a magisterial document and therefore couldn’t change or “loosen” Church teaching. Still, as a product of the Vatican, it should clearly and accurately present magisterial teaching on an issue that is complex and, as the book itself recognizes, often misunderstood. That being said, I think Fr. Pacholczyk is right that the Little Lexicon’s treatment of ANH is consistent with prior magisterial teaching—after all, it explicitly states that it’s explanation of the issue should be read in line with the Congregation (now Dicastery) for the Doctrine of the Faith’s 2007 document on the issue. On the other hand, the concerns about the book’s treatment of ANH are not “much ado about nothing”; it departs from earlier documents in how it explains the issue, and therefore its arguments deserve scrutiny.
A note: Perhaps because the book is not a magisterial statement, it’s not available online, and so far, it has only been published in Italian. It’s available for sale at the PAL web site for 12 euros! I have obtained a copy, however, and will provide unofficial translations of key passages throughout my commentary.
Before looking at what the Little Lexicon has to say, however, it’s crucial to examine earlier magisterial statements. The two most important are a 2004 address given by Pope John Paul II to an international congress on “Life-Sustaining Treatments and the Vegetative State: Scientific Advances and Ethical Dilemmas,” and a 2007 response by the Congregation for the Doctrine of Faith to two questions posed by the United States Conference of Catholic Bishops, already cited.
Pope John Paul II’s 2004 address focused on care for patients in a so-called “vegetative state,” that is, a condition in which a person has lost the brain functioning necessary for consciousness and awareness of one’s surroundings, but where the brain continues to regulate automatic functions like breathing, heartbeat, and reflexes. The address was notable for its timing as well as its content. For one, it came near the end of the pope’s own life, as his health was failing, and was seen as a bold affirmation of the dignity of the human person at the end of life. The address also came in the midst of the controversy in the United States over the fate of Terri Schiavo, a woman who was diagnosed as being in a persistent vegetative state after suffering cardiac arrest in 1990; a legal dispute between her husband and her parents over removing her feeding tube began in 1998 and ended in 2005 when the feeding tube was finally removed, leading to her death.
John Paul’s address begins by urging caution about the diagnostic term “permanent vegetative state,” given the fact that some patients have at least partially recovered from such a state after many years and given the uncertainty regarding the chances of recovery (#2). He goes on to affirm the dignity of patients in a vegetative state (#3), countering secular arguments that patients without consciousness are not truly persons, as well as the arguments of some Catholic ethicists that, absent consciousness, the life of a patient is only a “premoral good” that can be outweighed by other goods.
Then, in the key passage, he states:
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 [sic] confinement to bed. He also has the right to appropriate rehabilitative care and to be monitored for clinical signs of eventual recovery.
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. (#4, emphasis in original)
In the passage, John Paul makes two crucial points. First, he distinguishes “natural means of preserving life,” which can also be described as “normal care” or “basic health care,” from “medical acts” or medical interventions, and he states that ANH falls within the first category. Second, he states that ANH should be considered “in principle, ordinary and proportionate, and as such morally obligatory.” In the language of bioethics, an ordinary means of treatment is one that is obligatory whereas an extraordinary means of treatment is one that can be foregone or withheld. Similarly, a treatment is proportionate if its benefits will outweigh the burdens caused, whereas the treatment is disproportionate if it causes more burden than benefit.
In the following paragraph, John Paul suggests that withdrawing ANH in response to a diagnosis that a patient has entered a permanent vegetative state amounts to euthanasia:
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. (#4, emphasis in original)
This, together with the statement that ANH should, in principle, be considered morally obligatory, led some to conclude that John Paul was proposing an absolute prohibition on withdrawing ANH, at least until the patient was on the verge of death. Probably the majority of Catholic bioethicists, however, insisted that when John Paul said, “in principle,” this should be read as admitting of exceptions in particular cases, for example when the patient’s body proved incapable of assimilating nutrition. For example, the National Catholic Bioethics Center wrote at the time, in response to John Paul’s address:
[I]n general the provision of nutrition and hydration to the patient in the vegetative state is proportionate and morally obligatory, but . . . in a particular case nutrition and hydration may be extraordinary and disproportionate, and, therefore, morally optional.
To seek greater clarity, the USCCB’s Committee on Doctrine submitted two questions to the CDF in 2005, and the CDF responded in 2007. (John Allen notes the coincidence that, in 2005, Cardinal William Levada, the Archbishop of San Francisco, was the chair of the Committee on Doctrine, and by 2007 he had been appointed the Prefect of the CDF, so in essence he answered his own questions!) The first question asked:
Is the administration of food and water (whether by natural or artificial means) to a patient in a “vegetative state” morally obligatory except when they cannot be assimilated by the patient’s body or cannot be administered to the patient without causing significant physical discomfort?
The CDF replied:
Yes. The administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life. It is therefore obligatory to the extent to which, and for as long as, it is shown to accomplish its proper finality, which is the hydration and nourishment of the patient. In this way suffering and death by starvation and dehydration are prevented.
This response therefore clarified that ANH is morally obligatory in principle but could be withdrawn in exceptional circumstances like those mentioned in the question, when nutrition cannot be assimilated by the patient’s body or when ANH causes “significant physical discomfort,” or in other words when it is overly burdensome.
The second question asked:
When nutrition and hydration are being supplied by artificial means to a patient in a “permanent vegetative state”, may they be discontinued when competent physicians judge with moral certainty that the patient will never recover consciousness?
The CDF responded:
No. A patient in a “permanent vegetative state” is a person with fundamental human dignity and must, therefore, receive ordinary and proportionate care which includes, in principle, the administration of water and food even by artificial means.
This response simply affirmed what John Paul had said in his earlier address, that a diagnosis that a patient is in a permanent vegetative state, considered in itself, is not a sufficient justification for withdrawing ANH.
Notably, in neither response does the CDF appeal to the distinction made by John Paul II between “basic health care” and “medical acts,” although that may simply be because the issue was not raised in the questions posed.
How does the treatment of ANH in the Little Lexicon relate to these earlier magisterial statements? I think there are three key points worth pointing out.
In the first place, the book appears to claim that ANH should be considered a medical intervention, in clear contradistinction to Pope John Paul II’s teaching. It states, “[W]hat is put into the body is prepared in a laboratory and administered through technical devices, by prescription and through a medical intervention.” It adds that “the leading medical societies unanimously define ANH as a medical/health treatment for all intents and purposes,” a conclusion incorporated into law in Italy and several other countries.
It goes on to admit some ambiguity on the question, however: “The delicacy of the issue arises from the fact that food and water, on the one hand, are elements of great symbolic value in human relationships, and, on the other hand, refraining from administering them would lead to death by starvation and thirst.” Although the book doesn’t explicitly say so, these comments seem to suggest that ANH has some of the characteristics of basic care. The Little Lexicon doesn’t resolve this ambiguity, although to me it does seem to lean toward the conclusion that the administration of ANH should be considered a medical act.
Second, the Little Lexicon states that the withdrawal of ANH should not, ipso facto, be considered euthanasia. It explains:
Now, in diseases in which there is a prolonged state of unconsciousness with practically no chance of recovery—as in the case of the permanent vegetative state (PVS)—it could be argued that when ANH is discontinued, death is not caused by the disease taking its course, but rather by the action of those who suspend it. There would then be a difference from assisted ventilation, which is also a life-support device, but whose suspension, under certain conditions, raises no objection because respiratory failure is part of the ongoing pathology.
On closer inspection, however, this argument falls victim to a reductive conception of disease, which is understood as an alteration of a particular function of the body, losing sight of the totality of the person. This reductive way of interpreting illness then leads to an equally reductive conception of care, which ends up focusing on the individual functions of the organism rather than on the overall good of the person. The individual functions of the organism, including nutrition—especially when impacted in a stable and irreversible way—should be considered in light of the overall picture of the person and his or her bodily dimension.
As the first cited paragraph states, Catholic ethicists have long argued that the withdrawal of artificial respiration can in some cases be justified because, even though the death of the patient necessarily follows from the removal of the ventilator, the true cause of death is the underlying condition hindering the patient’s breathing and not the removal of the ventilator. The same principle would apply in other cases, as well—for example, a patient could refuse to continue with an onerous cancer treatment with only a small chance of success, even if this hastens his or her eventual death from the cancer.
Recall, however, that in his 2004 address, Pope John Paul had stated that the removal of ANH upon the diagnosis that a patient is in a permanent vegetative state would be considered euthanasia because hunger and thirst would be the cause of death. The Little Lexicon seems to reject this claim, suggesting that ANH should be treated more like artificial respiration.
John Paul’s statement, however, addressed cases in which ANH was withdrawn simply because the patient had been diagnosed as being in a PVS. As the CDF later clarified, ANH can be withdrawn in cases where it is more burdensome than beneficial, which seems to be the point of the admittedly vague second paragraph cited above, that the benefit of ANH for a patient needs to be considered in light of the totality of the patient’s well-being. What the Little Lexicon seems to be rejecting here is the claim that the removal of ANH should always be considered euthanasia, a claim that John Paul never made and one that is likewise belied by the CDF’s responses.
Indeed, thirdly, the Little Lexicon concludes its section on ANH by stating that its treatment of the issue can be understood as consistent with the CDF’s teaching in the 2007 document:
The application of this affirmation [i.e., that patient care should take into consideration the totality of the person and not just individual functions of the body] to the context of artificial nutrition and feeding [sic] does not necessarily conflict with what has been maintained by the Congregation for the Doctrine of the Faith.
Although the wording here is a bit silly and needlessly provocative (if the book’s remarks on ANH don’t necessarily conflict with the CDF’s teachings, does that mean that maybe they do?), the Little Lexicon goes through the principles outlined in the 2007 CDF document, concluding that they have general applicability but require discernment in their application to concrete cases, which of course is what the CDF had said, as well.
Based on my reading, then, the PAL’s Little Lexicon for the End of Life departs from John Paul II by suggesting that administering ANH is a medical act and not simply a matter of normal care, but otherwise it follows prior magisterial teaching that ANH should in principle be considered morally obligatory, even if under certain circumstances it can become overly burdensome and therefore no longer obligatory.
In my view, the Little Lexicon would have been better off more explicitly stating that the question of whether ANH should be considered a medical intervention or basic health care is complex and the answer ambiguous. For example, the Little Lexicon states:
Artificial nutrition and hydration is used to nourish a patient when such an outcome can no longer be achieved through the ordinary oral mode. The necessary nutrients (such as water, sugars, amino acids, vitamins, electrolytes, etc.) are administered by different techniques, either parenterally (e.g., intravenously) or enterally. In the latter case, a nasogastric tube or percutaneous endoscopic gastrostomy tube (abbreviated as PEG tube, from the English expression) is routinely used, which allows the necessary substances to be introduced directly into the stomach, through the abdominal wall.
This description clearly emphasizes the technical aspects of ANH. On the other hand, as Camosy points out in his commentary on the Little Lexicon:
The nutrition given to such disabled human beings is no more made in a laboratory than a protein shake powder. And feeding tubes are extremely simple devices that don’t require any machine or other special technology.
Many Catholic bioethicists would see feeding a disabled person through a tube as little different from feeding them with a spoon. Both are “technology” in a strict sense, but both are examples of basic Christian care for the needy (“feeding the hungry”), not medical treatment.
I think both raise good points, and I would argue that in the case of ANH, it is impossible to make a sharp distinction between a medical intervention and basic health care, and I imagine there are other instances where the distinction doesn’t hold up, as well.
Camosy fears that, without this distinction, medical professionals will be more willing to withhold ANH:
[T]he pontifical academy’s new text appears to suggest that, because the food and hydration given to disabled, so-called “vegetative” patients is prepared in a laboratory and administered through technology, offering them to such patients does not amount to “simple care procedures.”
It could therefore be thought of as a medical treatment which could, in principle, be withdrawn, rather than the kind of basic care which can never be withheld.
But, as we’ve already seen, not even the CDF has insisted that ANH can never be withheld. Indeed, in traditional Catholic teaching, even providing food and drink using normal (i.e., non-artificial) means ceases to be morally obligatory when it is overly burdensome to the patient, although of course other treatments that could help make eating and drinking more tolerable should be used, if available. Similarly, it’s not at all clear why treating ANH as a medical intervention is incompatible with the view that, in principle, it should be treated as ordinary and proportionate.
I think, therefore, the Little Lexicon’s significance is not that that it “loosens” the Catholic Church’s stance on providing ANH to patients, but rather that it revisits John Paul’s conclusion that ANH should not be considered a medical intervention, but rather a form of basic health care. The Little Lexicon seems to suggest that this is compatible with what the Church has said about the obligatoriness of providing ANH, and I tend to agree. But given that the purpose of the book was to provide clarity regarding Catholic teaching on bioethics in our contemporary secular context, raising that question in this particular publication, and with so little exposition, was probably inopportune.
Of Interest…
Earlier this month, the Peruvian bishops conference announced that Pope Francis had expelled the founder of the movement known as the Sodalitium Christianae Vitae from that organization. The Vatican decree cited by the Peruvian bishops stated that Luis Fernando Figari had engaged in unacceptable behavior and caused scandal to the faithful. A years-long investigation by the Vatican, as well as the work of Peruvian journalists, uncovered that Figari and other leaders of the SCV had engaged in sexual and psychological abuse of young people under the care of the organization. Earlier this year, Pope Francis had accepted the resignation of Archbishop José Antonio Eguren of Piura, who was affiliated with the SCV and was involved in a real estate scandal involving the organization. Eguren resigned at the age of 67, eight years before the mandatory retirement age for bishops. Now this past week, Pope Francis met with Eguren in the Vatican, although it is not clear for what purpose, or whether the meeting was at Francis’s request or Eguren’s. In Peru, the SCV is linked with the political far right, and ecclesially is associated with the more traditionalist wing of the Catholic Church. It’s one of a handful of Latin American Catholic organizations that was promoted by Popes John Paul II and Benedict XVI despite their far-right tendencies and ambiguous attitude toward Vatican II. It’s not clear what path lies ahead for the SCV after the Vatican’s investigation and Figari’s removal, but the discrediting of the organization represents a turning point in the internal politics of the Latin American Church.
I believe that one of the most important outcomes of the Synod on Synodality will be a re-evaluation of what leadership in the Catholic Church should look like, all the way from the papal and episcopal levels to the leadership of parish councils and youth ministries. Writing in Commonweal, author Kathleen Brady has an excellent article on the leadership of St. Clare of Assisi, the founder of the Second Order of Franciscans, the Poor Clares. Brady links Clare to the modern notion of servant leadership, which of course has Christian roots. A servant leader is one who uses their position to promote the well-being of those for whom they are responsible. Brady makes a compelling case that Clare was both a servant and a leader, exhibiting humility and promoting the holiness of the women under her care, but also acting boldly and decisively when needed. Looking to today, servant leadership is certainly one dimension of the synodal leadership the Church needs, but as contemporary scholars of leadership have noted, the model of servant leadership downplays other, important aspects of leadership: a commitment to the organization, the ability to create and communicate an inspiring vision, and skill at setting goals consistent with that vision and developing a plan for achieving them. Clare certainly demonstrated those qualities, as well, and her example shows that synodal leadership for today’s Church will likewise need to be multifaceted.