Wojda on Advance Directives in PVS

My colleague Paul Wojda offers this response to the comment on his question on advance directives dealing with the possibility of a PVS:

With respect to interpreting official Church teaching on this issue I think it’s important to recognize a number of trajectories, some of which may be in tension with others. The first and most obvious trajectory is the continued resistance to modern trends that diminish human life. In this light, those who don’t “get” John Paul II’s allocution on nutrition/hydration would do well to look at his (and the U.S. Bishops’) many statements on war and peace, economic justice, capital punishment, and (of course) abortion. In each of these areas Church teaching has been at pains to narrow, if not close entirely, the permissible exceptions to the prohibition against taking life. The increasing emphasis on the public duties of Catholic officials is part of this trajectory too (i.e., not just to always “tolerate” evil but to work to ameliorate threats to human life). All of this has been accentuated by the dyad “culture of life/death” made popular in The Gospel of Life (1995).

The trajectory regarding permissible cessation or foregoing of life-prolonging care is of much older stock, however, and while it operates with an eye to social/political/cultural circumstances, it is far more casuistic and thus person-centered than this first trajectory. Medical decisions must, necessarily, be made in good conscience by the patient herself. And in this tradition it has always been understood that even food and water (or other non-medical forms of care) may be legitimately refused by a person if they are judged—by the patient—to be either excessively burdensome and/or offer little or no hope of benefit. This tradition has proven remarkably supple as our capacity to prolong life has increased, especially so over the last half-century, but its crucial moral feature—that we never directly aim at the death of ourselves or another—is still very much alive, as even Vacco (1997) demonstrates. More importantly, Pius XII in his famous 1957 address to Anaesthesiologists explicitly affirms this “patient-centered” approach: 

“The rights and duties of the doctor are correlative to those of the patient. The doctor, in fact, has no separate or independent right where the patient is concerned. In general he can take action only if the patient explicitly or implicitly, directly or indirectly, gives him permission. The technique of resuscitation which concerns us here does not contain anything immoral in itself. Therefore the patient, if he were capable of making a personal decision, could lawfully use it and, consequently, give the doctor permission to use it. On the other hand, since these forms of treatment go beyond the ordinary means to which one is bound, it cannot be held that there is an obligation to use them nor, consequently, that one is bound to give the doctor permission to use them.”

There are obviously other factors involved besides the patient’s right to make health care decisions, but the principle is clear.

Thus my original question (now rephrased in light of your comments): can I know in advance (with moral, not mathematical certainty), and stipulate with the necessary clarity, that certain forms of care (medical and otherwise) would be excessively burdensome and/or offer no reasonable hope of benefit, and that therefore I would wish them to be discontinued? 

I think the answer is plainly yes, on both counts, and I think that a reliable medical diagnosis of PVS after one year of artificially administered food and water (in the medically verified instance of an inability to swallow) is such a situation. How rare or exceptional these situations might be is a matter for further debate. (Anecdotal evidence suggests that many if not most Catholics would deem MANH to offer no reasonable benefit in this scenario. Indeed, most people I talk to at parishes etc. are rather frightened—not to mention monumentally confused—at what they hear the Church telling them: that they are obliged under pain of mortal sin to maintain MANH if in a PVS, no matter how long.)

My concern is that this trajectory of principled casuistry is being lost amidst the trajectory of (necessary) public witness to the dignity of human life in the mode of cultural critique. In our necessary opposition to euthanasia and physician-assisted suicide we must also preserve and develop the practice of a charitable reason that is grounded, in these matters, in the awareness that while life is an obligation it is because it is first a gift.