Mirror of Justice

Lisa Sowle Cahill, as many of you know, is a distinguished professor of theology at Boston College.  In the April 25th issue of America, she has an essay titled Catholicism, Death, and Modern Medicine.  One has to be a subscriber to access the piece.  An excerpt follows:

The Ethical and Religious Directives for Catholic Health Care Services, published by the U.S. Bishops (fourth edition, 2001), maintain the same: “Disproportionate means are those that in the patient’s judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.” The directives go on to stipulate: “There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient.”

Over the past several years, different theologians, bishops and bishops’ conferences have offered differing views about whether and when artificial nutrition should be considered an extraordinary or disproportionate means. The issue is particularly difficult in the case of persons who are comatose or in a “persistent vegetative state,” and hence unable to perceive their own condition, suffer consciously or consciously appreciate the prospect of extended life. Ultimately, the question is whether extended life in a state of permanent unconsciousness is a benefit or a burden to human dignity. A related question is whether the interests of others—either family members or others who lack access to medical resources—should be relevant in determining whether a means is “disproportionate” for a given patient, especially since traditional sources relate the welfare of the individual patient to family and communal relationships.

Those who demanded that Terri Schiavo be maintained indefinitely by artificial hydration and nutrition disputed the consensus of reliable medical experts that her condition was permanent; claimed that continued life would be a benefit no matter what its condition; asserted that her parents’ interest in keeping her alive should be determinative; presented the withdrawal of artificial nutrition as “starvation” and “murder”; presented Ms. Schiavo as an innocent victim who deserved better protection from society, the courts and the law; and placed her case at the top of a “slippery slope” toward the murder of other disabled or disadvantaged members of society.

The debate about whether the use of medically assisted nutrition and hydration is mandatory in such cases was not clearly resolved by a speech on the subject by John Paul II in March 2004. (Although the identity of the author has been debated, it was almost certainly not the pope himself.) In this talk, “Life-Sustaining Treatments and Vegetative State,” he said that affected persons have “the right to basic health care.” He asserted “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 “should be considered, in principle, ordinary and proportionate, and as such morally obligatory,” as long as it is “providing nourishment to the patient and alleviation of his suffering.” He referred to withdrawal as “starvation” and “euthanasia by omission.”

While some applauded this speech as an important step in the direction of protecting innocent patients from harm, others saw it as marked by non sequiturs and inconsistencies, and as not ultimately settling the question in favor of always using artificial nutrition. For one thing, it is hard to see how tube feeding can flatly be judged “not a medical act.” For another, official teaching specifically permits the removal of ventilors (respirators), knowing that death will ensue, without referring to the outcome as “smothering” the patient. In both cases, it would seem, the rejection of the means of life-prolongation is not tantamount to directly desiring that the patient be dead, but rather to acceptance of death as now timely and a part of the human condition. Moreover, the reference to “alleviation of suffering” suggests that the papal remarks apply only to conscious patients. Most important, the speech is not consistent with prior well-established teaching and health care practices in Catholic institutions, as defined by the Declaration on Euthanasia and the Ethical and Religious Directives. In fact, artificial nutrition is not generally a part of hospice care, even though it was provided to Terri Schiavo. According to good medical evidence (e.g., The New England Journal of Medicine, July 2003), the dying process is neither painful nor uncomfortable without it.

Richard Doerflinger, of the U. S. Bishops’ Secretariat for Pro-Life Activities, said that “the Holy Father has not declared an absolute moral obligation to provide assisted feeding in all cases” (Ethics and Medics, June 2004). The Catholic Health Association referred health care providers to the Ethical and Religious Directives as the context for the interpretation of the papal speech. Neither those directives nor the 1980 declaration have been revoked by the Vatican, nor have Vatican officials taken steps to insist that all patients who cannot ingest food or fluids be intubated for artificial feeding.
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The key question in this case should have been, “What is in the best interests of Terri Schiavo?” Leaving the tubes in place cannot be simplistically equated with acting in her interests, since it could reasonably be argued that 15 or more years of existence in a “vegetative” state neither serves human dignity nor presents a fate that most reasonable people would obviously prefer to death. Those who saw continued tube feeding as a protection of the pro-life position and as a strike in favor of defenseless patients are mistaken if they think that expanding the definition of “ordinary” care will prevent unjust termination of life in health care settings. It is just as likely to worry those who want prudent judgments about their own best interests to be made by family members when their time comes. It may even contribute to the present movement for physician-assisted suicide, which is partly a backlash against the overuse of hi-tech care at the end of life.

On the other side, those who favor an approach more favorable to foregoing artificial feeding suffer under the misconception that the pro-life concerns are simply reactionary and misguided. Many disability-rights activists and organizations, as well as Jesse Jackson, joined hands with the Schindlers. This points up legitimate fears that medical decision-making often reflects utilitarian cost-saving standards, control by “elite” values and interests, and the continued marginalization from medical services of those who lack financial resources and a political voice. The sad story of Terri Schiavo calls for more pastorally sensitive and holistic care for those in similar situations, and better and more readily available hospice care for all. It cries out for the use of advance directives along with designated proxies to evaluate “best interests” as circumstances develop.

The Schiavo case is a warning for all concerned about the common good to become better advocates for broad national health care reform. Sane, just and morally acceptable health care would take the emphasis off expensive, specialized and excessive “treatment” for a few (who may well not have chosen it) and put it where the moral debate should be: integrated, humane health services for everyone who needs them.
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Michael P.