Artificial Nutrition and Hydration and the Permanently Unconscious Patient: The Catholic Debate

Introduction: The State of the Debate

Introduction The฀State฀of฀the฀Debate The฀debate฀about฀forgoing฀or฀withdrawing฀artificial฀nutrition฀and฀hydration,฀ especially฀regarding฀patients฀in฀a฀persistent฀vegetative฀state,฀dates฀back฀at฀least฀ to฀the฀early฀1980s.฀High-profile฀cases฀brought฀the฀issue฀to฀the฀fore฀and฀to฀the฀ attention฀of฀clinicians,฀bioethicists,฀theologians,฀attorneys,฀legislators,฀and฀the฀ general฀public:฀In฀the฀1982฀Baby฀Doe฀case,฀an฀infant฀with฀Down฀syndrome฀and฀ esophageal฀atresia฀was฀denied฀artificial฀nutrition฀and฀hydration;฀in฀the฀1983฀ Clarence฀Herbert฀case,฀two฀physicians฀were฀charged฀with฀murder฀for฀discontinuing ฀nutrition฀and฀hydration฀for฀a฀patient฀who฀had฀suffered฀a฀profound฀anoxic฀ brain฀injury;฀and฀in฀the฀1983฀Claire฀Conroy฀case,฀a฀nephew฀requested฀discontinuation ฀of฀artificial฀nutrition฀and฀hydration฀on฀his฀elderly,฀demented฀aunt฀who฀ resided฀in฀a฀nursing฀home. Subsequent฀high-profile฀cases฀continued฀to฀fuel฀the฀debate฀while฀clinicians฀ frequently฀struggled฀with฀decisions฀about฀withdrawing฀feeding฀tubes฀for฀the฀ many฀patients฀who฀did฀not฀make฀the฀evening฀news฀or฀the฀front฀page฀of฀the฀ newspaper.฀A฀good฀deal฀of฀literature,฀both฀secular฀and฀religious,฀was฀generated ฀in฀response฀to฀the฀cases฀themselves฀and฀in฀response฀to฀the฀situations฀they฀ represented.฀Whereas฀some฀people฀considered฀feeding฀tubes฀as฀another฀form฀ of฀life-sustaining฀treatment฀subject฀to฀a฀burden–benefit฀analysis,฀others฀viewed฀ them฀as฀a฀basic฀form฀of฀care฀and฀generally฀morally฀obligatory.฀Still฀others฀might฀ permit฀the฀withdrawal฀of฀feeding฀tubes฀in฀patients฀who฀are฀imminently฀dying฀ but฀not฀in฀patients฀in฀a฀persistent฀vegetative฀state฀(PVS).฀It฀is฀the฀latter฀that฀has฀ become฀the฀flash฀point฀in฀the฀debate฀about฀forgoing฀or฀withdrawing฀artificial฀ nutrition฀and฀hydration,฀as฀was฀evidenced฀in฀the฀recent฀Terri฀Schiavo฀case฀and฀in฀ reactions฀to฀the฀2004฀address฀of฀John฀Paul฀II฀on฀“Care฀for฀Patients฀in฀a฀‘Permanent ’฀Vegetative฀State.”฀It฀is฀the฀papal฀speech฀that฀is฀especially฀the฀focus฀of฀this฀ ฀ volume. What฀accounts฀for฀the฀enormous฀differences฀in฀perspective฀between฀those฀ who฀believe฀that฀forgoing฀or฀withdrawing฀artificial฀nutrition฀and฀hydration฀for฀ patients฀in฀a฀persistent฀vegetative฀state฀is฀morally฀permissible฀and฀those฀who฀do฀ ฀ 1 not?฀The฀major฀differences฀seem฀to฀revolve฀around฀three฀issues—one฀clinical฀ and฀two฀ethical. The฀Nature฀and฀Prognosis฀of฀Persistent฀Vegetative฀State One฀of฀the฀fundamental฀differences฀between฀the฀two฀positions฀is฀how฀one฀thinks฀ about฀persons฀in฀a฀persistent฀vegetative฀state.฀Are฀they฀dying฀or฀are฀they฀merely฀ seriously฀disabled?฀Some฀people฀maintain฀that฀these฀individuals,฀although฀not฀ dying฀in฀the฀same฀sense฀as฀someone฀with฀terminal฀cancer,฀do฀have฀a฀fatal฀pathology ฀that฀would฀lead฀to฀their฀death฀if฀they฀do฀not฀receive฀medical฀intervention ฀(similar฀to฀patients฀with฀kidney฀failure฀who฀require฀dialysis).฀They฀believe฀ artificial฀nutrition฀and฀hydration฀in฀such฀patients฀represents฀a฀form฀of฀life-฀ sustaining฀treatment.฀Forgoing฀or฀withdrawing฀this฀medical฀intervention฀would฀ be฀an฀instance฀of฀“allowing฀the฀patient฀to฀die,”฀and,฀therefore,฀consistent฀with฀ the฀Catholic฀moral฀tradition.฀Discontinuing฀artificial฀nutrition฀and฀hydration฀is฀ the฀cessation฀of฀an฀intervention฀that฀will฀not฀improve฀the฀patient’s฀condition฀or฀ restore฀the฀person฀to฀health. ฀ Others,฀however,฀do฀not฀regard฀the฀person฀in฀a฀persistent฀vegetative฀state฀as฀ dying฀but฀as฀seriously฀disabled.฀They฀believe฀artificial฀nutrition฀and฀hydration฀ is฀a฀form฀of฀basic฀care฀due฀to฀any฀human฀being,฀just฀like฀bathing,฀and฀it฀is฀not฀ a฀life-sustaining฀treatment.฀Forgoing฀or฀withdrawing฀this฀type฀of฀care฀in฀a฀nondying ฀individual฀would฀be฀the฀direct฀cause฀of฀his฀or฀her฀death฀and฀would฀be฀an฀ instance฀of฀unjustified฀killing.฀It฀would฀constitute฀euthanasia฀by฀omission. ฀ Other฀concerns฀relating฀to฀the฀nature฀of฀persistent฀vegetative฀state฀that฀account ฀for฀the฀differing฀perspectives฀have฀to฀do฀with฀the฀frequency฀of฀misdiagnoses ,฀the฀possibility฀of฀“recovery”฀from฀PVS฀and฀what฀that฀recovery฀consists฀ of,฀and฀whether฀persons฀in฀PVS฀can฀experience฀pain฀and฀suffering. Human฀Life Another฀fundamental฀difference฀between฀the฀two฀positions฀is฀how฀each฀regards฀ unconscious฀biological฀life.฀Catholic฀moral฀theologians฀writing฀on฀this฀issue฀ have฀a฀profound฀regard฀for฀the฀person฀in฀PVS.฀There฀is฀agreement฀that฀such฀ individuals฀retain฀their฀full฀human฀dignity.฀No฀one฀claims฀that฀these฀persons฀ are฀of฀less฀value฀because฀of฀their฀condition฀or฀that฀their฀lives฀are฀not฀worth฀ sustaining. 2฀ ฀  Some฀people,฀however,฀believe฀that฀persons฀in฀PVS฀have฀forever฀lost฀their฀ ability฀to฀pursue฀life’s฀goods฀and฀life’s฀goals฀and฀argue...