The Italian "Letting Die" Case Revisited

The Tablet
January 6, 2007

A life too burdensome
John Paris

Last month the Italian poet and muscular dystrophy sufferer Piergiorgio Welby was granted his wish when a doctor turned off the ventilator that had been keeping him alive. The Church refused Welby a Catholic funeral. But did this refusal accord with the Church's teaching on when a person can be allowed to die?

What, if any, is the difference between killing a patient and letting him die? Or euthanasia and the withdrawal of life-sustaining medical interventions?

These issues once again captured the world's attention when Piergiorgio Welby, an Italian poet and a long-time advocate for euthanasia, composed an eloquent letter to the President of Italy pleading to be allowed to die. "I love life, Mr President," he wrote. But after 40 years of battling muscular dystrophy and nine years attached to a ventilator, Welby was losing his capacity to speak or to eat. He concluded his letter with the words: "What is left to me is no longer a life. It is an unbearable torture." He then asked to be allowed to have his ventilator removed. That request, honoured on a regular basis in hospitals across the world, caused uproar in Italy. His plea was denounced by critics as a demand for suicide or euthanasia. After a doctor defied an Italian court ruling and switched off the ventilator the Diocese of Rome denied Welby a Catholic funeral. Church officials said his "will to end his life was known, as it had been repeated and publicly affirmed, in contrast to Catholic doctrine".

Earlier, the judge ruled that while Welby had a constitutional right to be free of unwanted medical treatment, Italy's medical code "requires doctors to maintain the life of a patient". "Physicians", she wrote, "even when faced with the request of the patient, must not carry out ... treatments aimed at causing death." The judge concluded her opinion with the observation that Italy's penal code outlaws the "homicide of a consenting person and helping [someone] to commit suicide".

How in Catholic Italy did such confusion arise over the distinction between withdrawal of burdensome medical interventions and suicide/killing? In America, the courts and the American Medical Association have categorised both artificially supplied nutrition and fluids and the use of ventilators as medical interventions. The Church's teaching has in the main agreed with this. A notable exception was John Paul II's "Allocation" in 2004 to the Pontifical Council for Life in which he was quoted as saying, "artificial nutrition and fluids are natural means and thus always obligatory". But this statement was a one-off, delivered to a private audience, and had no theological basis. It was never repeated by Pope John Paul, nor has it been by his successor, Pope Benedict.

Much more reliable is the Vatican's 1980 Declaration on Euthanasia, which states: "One cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide [or euthanasia]; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected."

And yet when faced with highly publicised decisions on the withdrawing of life-prolonging medical treatment from patients, the Church's view as expressed locally has not been consistent. The reasons for this can best be understood by tracing the history of the Church's teaching that one need not employ "extraordinary" measures to prolong life. This goes back to the distinction first proposed in 1595 by Domingo Bañez between "extraordinary" and "ordinary" means - by which was meant measures proportionate to one's condition or state in life. When discussing what one must do to sustain life, theologians were referring not to hardware or techniques, but to "moral" obligation, i.e. what one must do to avoid sinning. The penalty for failure to fulfil such a duty was, of course, eternal damnation.

Given the context of one's eternal salvation, the question immediately arose as to the limits, if any, of the obligation to sustain life. The clearest statement of the limits is found in the Relationes Theologiae (1587) by the sixteenth- century Dominican moralist Francisco de Vitoria. In a commentary on the obligation to use food to preserve life De Vitoria asks: "Would a sick person who does not eat because of some disgust for food be guilty of a sin equivalent to suicide?" His reply: "If a patient is so depressed or has lost his appetite so that it is only with the greatest effort that he can eat food, this right away ought to be reckoned as creating a kind of impossibility, and the patient is excused, at least from moral sin, especially if there is little or no hope of life."

That De Vitoria's views were neither unique nor subsequently abandoned is best seen in a 1950 Theological Studies essay on "The Duty of Using Artificial Means of Preserving Life" by the widely respected Jesuit moralist Gerald Kelly. After a thorough review of prior teachings on the topic, Kelly finds that the authors hold that "no remedy is obligatory unless it offers a reasonable hope of checking or curing a disease [Nemo ad inutile tenatur]." From this Kelly concludes that no one is obliged to use any means - natural or artificial - if it does not offer a reasonable hope of success in overcoming the patient's condition.

How, then, did the idea arise that life-prolonging medical treatments once in place may not legitimately be removed? The answer is found further on in Kelly's own essay where he writes: "I frankly hesitate to give a practical answer allowing the physician to discontinue the intravenous feeding as a means to end suffering. I fear the abrupt ceasing of nourishment to a conscious patient might appear to be a sort of ‘Catholic euthanasia' to many who cannot appreciate the fine distinction between omitting an ordinary means and omitting a useless ordinary means."

That reluctance was intensified in Charles McFadden's widely used Medical Ethics first published in 1961. McFadden wrote that while the long-term use of artificial feedings could constitute a grave and non-obligatory burden, as a matter of practical medical advice he would never propose the removal of intravenous feeding once it had been instituted. The danger is that of scandal, guilt on the part of the family and misuse by insensitive or unscrupulous physicians. Those not familiar with nuanced distinctions, he argued, might believe that the patient had been deliberately killed to alleviate his suffering. Others then might all too readily terminate nourishment for anyone whose life was considered "useless".

The issue of withdrawal of life-prolonging treatment fairly much dropped from the literature from the 1960s until in 1976 the case of Karen Ann Quinlan once again thrust the topic back into public attention. Karen was 21 when she fell unconscious after coming home from a party. She was taken to hospital and put on a ventilator but never regained consciousness. Some months later her family embarked on a legal battle to oblige doctors to discontinue active care. In testimony before the President's Commission on Ethical Problems in Medicine, Richard A. McCormick SJ, a professor of moral theology at Georgetown University, was asked whether there was any moral difference between removing a respirator, antibiotics or artificial feeding from Karen Ann Quinlan. His reply was that from the Catholic tradition the answer was clearly "No". However McCormick, aware of the danger of misinterpretation and misuse of the Catholic principle - as well as the forces in American society that would welcome the highly publicised withdrawal of nutrition from Quinlan as an invitation to active euthanasia - cautioned that it might be imprudent to withdraw artificial feeding in her particular well-publicised case. The court gave authorisation to the family's request for the ventilator to be switched off. Artificial feeding in this case continued at the family's request and Karen survived for almost a decade in a coma until she succumbed to pneumonia.

A whole spate of similar cases soon followed in the United States. In one of these, that of Nancy Ellen Jobes (1987), a New Jersey court authorised the withdrawal of artificial nutrition and fluids from a woman in a well-defined persistent vegetative state. In a submission to the New Jersey Supreme Court, the New Jersey Catholic Conference of Bishops issued a plea not to allow "euthanasia" and not to lessen the respect for the human life of patients who are seriously ill or dying. In their brief the bishops reminded the court that a person, so long as he or she exists - regardless of condition, regardless of stated wishes, regardless of suffering and the burden of continued life - must not be allowed to remove life-sustaining artificial nutrition and fluids. 

Some Catholic commentators said the same about the case of Tony Bland in Britain and Terri Schiavo in America, two other high-profile cases concerned with the removal of artificial feeding and hydration. That they should also criticise as "euthanasia" what happened with Piergiorgio Welby is more than perplexing since he was on a ventilator and well able to articulate his wishes.

However, Archbishop Mario Conti of Glasgow recognised that a ventilator does constitute medical intervention in his comment on the case of Miss B. which occurred in London in 2002. Miss B. was a 43-year-old woman who became paralysed from the neck down after a blood vessel ruptured in her neck. She successfully petitioned the High Court to have her ventilator switched off after doctors refused to comply with her request. Archbishop Conti commented: "The principle here [the request for the withdrawal of a ventilator] is quite different from euthanasia. The request in this case is not for assisted suicide, rather it is for the discontinuation of a medical procedure which is burdensome to the patient."

Richard McCormick, who understood both the Church's tradition as well as the danger of the Catholic teaching being misunderstood or misused by proponents of active euthanasia, insisted that the bedrock teaching of theology on the meaning of life and death - and not a misplaced debate on "the casuistry of means" - should guide our judgements on the difficult and sometimes trying issues cast up by modern medical technology. As he put it in an article McCormick and I co-authored on "The Catholic Tradition on the Use of Nutrition and Fluids" (America, 1987): "It is that tradition, developed over centuries of living out the gospel message on the meaning of life and death - not some immediate political ‘pro-life' agenda - that ought to be the source of our advice and guidance to courts."

The rich, nuanced and highly developed Catholic teaching that there is no duty to use medical measures artificially to prolong life is clear. "The problem" in the Welby case, notes Cardinal Javier Lozano Barragán, the Vatican's top official for health, in a recent interview in La Repubblica, "is to know if we find ourselves truly in front of a case of artificially prolonging life." Piergiorgio Welby responded to that question in his letter to the Italian President: "What is natural about a hole in the windpipe and a pump that blows air into the lungs? What is natural about a body kept biologically functional with the help of artificial respirators, artificial feed, artificial hydration, artificial intestinal emptying, of death artificially postponed?"

At the end of his long journey towards death Pope John Paul II declined the option of returning to Gemelli Hospital, where earlier his failing breathing was assisted by a respirator and his nutrition supplied through a feeding tube. Rather than return to those mechanisms that might have extended his earthly life John Paul II's parting plea was, "Let me go to the house of the Father." No one confused the Pope's action with suicide. Nor should they do so with Welby's refusal to endure what he described as "the unbearable torture" of being attached to a respirator.