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

17. Medically Assisted Nutrition and Hydration: A Contribution to the Dialogue

฀ 215 17 Medically฀Assisted฀Nutrition฀and฀Hydration:฀฀ A฀Contribution฀to฀the฀Dialogue Mark฀Repenshek฀ John฀Paul฀Slosar The฀Address฀to฀Participants฀in฀the฀International฀Congress฀on฀“Life-Sustaining฀Treatments฀and฀ the฀Vegetative฀State:฀Scientific฀Advances฀and฀Ethical฀Dilemmas,”฀promulgated฀in฀March฀of฀ this฀year฀by฀Pope฀John฀Paul฀II,฀has฀become฀a฀source฀of฀considerable฀controversy,฀ partly฀due฀to฀the฀theological฀and฀clinical฀complexity฀of฀this฀issue,฀and฀partly฀ because฀of฀how฀it฀has฀been฀portrayed฀in฀the฀popular฀media.1 ฀In฀light฀of฀this฀controversy ,฀many฀Catholics,฀as฀well฀as฀Catholic฀health฀systems,฀are฀re-examining฀ ฀ the฀half-millennium-old฀tradition฀of฀Catholic฀moral฀teaching฀regarding฀the฀obligation ฀to฀use฀particular฀means฀of฀sustaining฀human฀life.2 ฀In฀this฀essay,฀we฀seek฀ to฀foster฀that฀effort.฀In฀light฀of฀that฀tradition,฀and฀particularly฀the฀discussion฀ of฀the฀principles฀of฀proportionate฀and฀disproportionate฀means,฀we฀will฀propose฀ a฀way฀of฀interpreting฀the฀recent฀papal฀address฀that฀has฀not฀received฀significant฀ attention. The฀Duty฀to฀Sustain฀Life Perhaps฀the฀most฀fundamental฀tenet฀of฀the฀Roman฀Catholic฀moral฀tradition฀is฀ that฀life฀is฀a฀precious฀gift฀from฀God.3 ฀This฀conviction฀is฀the฀basis฀for฀a฀duty฀to฀ protect฀and฀preserve฀our฀lives,฀but฀that฀duty฀does฀not฀imply฀an฀obligation฀to฀use฀ every฀and฀all฀means฀available฀to฀sustain฀our฀lives฀at฀all฀costs.4 ฀Catholic฀moral฀ teaching฀holds฀that฀the฀ultimate฀end฀of฀human฀life฀lies฀with฀God฀and฀that฀life฀on฀ earth฀is฀itself฀only฀a฀penultimate฀good.฀As฀Pope฀Pius฀XII฀notes,฀“Life,฀health,฀all฀ temporal฀activities฀are฀in฀fact฀subordinated฀to฀spiritual฀ends.”5 ฀Reaffirming฀this฀ insight,฀Pope฀John฀Paul฀II฀wrote฀in฀Evangelium฀Vitae฀that฀“it฀is฀precisely฀[our]฀supernatural ฀calling฀which฀highlights฀the฀relative฀character฀of฀each฀individual’s฀earthly฀ life.฀After฀all,฀life฀on฀earth฀is฀not฀an฀‘ultimate’฀but฀a฀‘penultimate’฀reality.”6 Thomas฀Shannon฀and฀James฀Walter฀have฀recently฀pointed฀out฀that฀the฀resulting ฀duty฀to฀sustain฀life฀has฀traditionally฀been฀understood฀in฀the฀Roman฀ Catholic฀moral฀tradition฀as฀teleological.7 ฀In฀the฀context฀of฀the฀Catholic฀moral฀ tradition,฀“teleological”฀is฀not฀synonymous฀with฀consequentialist.฀Rather,฀as฀we฀ understand฀it,฀the฀teleological฀framework฀found฀within฀the฀Catholic฀tradition฀ recognizes฀the฀moral฀relevance฀both฀of฀rules฀of฀right฀conduct฀and฀of฀consequences .8 ฀In฀other฀words,฀the฀Catholic฀moral฀tradition฀has฀always฀recognized฀ some฀negative฀obligations฀of฀a฀fundamentally฀deontological฀nature,฀including฀ of฀course฀the฀obligation฀never฀to฀directly฀intend฀the฀destruction฀of฀innocent฀ human฀life.฀It฀is฀our฀view,฀however,฀that฀these฀deontological฀obligations฀do฀ not฀preclude฀the฀use฀of฀the฀principles฀of฀proportionate฀and฀disproportionate฀ means฀as฀teleological฀guides฀for฀discerning฀whether฀discontinuing฀a฀particular฀ life-sustaining฀treatment฀would฀constitute฀the฀directly฀intended฀destruction฀of฀ innocent฀human฀life. As฀defined฀by฀the฀Ethical฀and฀Religious฀Directives฀for฀Catholic฀Health฀Care฀Services฀ (ERD),฀a฀proportionate฀means฀is฀one฀that฀individuals฀are฀obligated฀to฀use฀to฀ preserve฀life฀insofar฀as,฀in฀the฀judgment฀of฀the฀patient,฀the฀means฀in฀question฀ offer฀a฀reasonable฀hope฀of฀benefit฀and฀do฀not฀entail฀excessive฀burdens.9 ฀One฀is฀ not฀obligated฀to฀use฀any฀means฀of฀sustaining฀life฀that,฀in฀one’s฀own฀judgment,฀ either฀do฀not฀offer฀a฀reasonable฀hope฀of฀benefit฀or฀entail฀excessive—that฀is,฀ disproportionate—burdens.฀The฀Catechism฀of฀the฀Catholic฀Church฀affirms฀this฀when฀ it฀says,฀ “Discontinuing฀medical฀procedures฀that฀are฀burdensome,฀dangerous,฀ extraordinary,฀or฀disproportionate฀to฀the฀expected฀outcome฀can฀be฀legitimate;฀it฀ is฀the฀refusal฀of฀‘over-zealous’฀treatment.฀Here฀one฀does฀not฀will฀to฀cause฀death;฀ one’s฀inability฀to฀impede฀it฀is฀merely฀accepted.”10 ฀It฀is฀important฀to฀note฀here฀ that฀neither฀the฀ERD฀nor฀the฀Catechism฀specify฀which฀procedures,฀diagnostics,฀or฀ therapies฀constitute฀proportionate฀or฀disproportionate฀means.฀In฀fact,฀the฀ERD฀ explicitly฀emphasize฀that฀those฀determinations฀are฀to฀be฀made฀“in฀the฀judgment฀ of฀the฀patient.” The฀Vatican’s฀1980฀Declaration฀on฀Euthanasia฀reaffirms฀these฀principles฀and฀the฀ nature฀of฀the฀moral฀obligation฀to฀use฀particular฀means฀of฀sustaining฀life.฀It฀ stated:฀ “It฀will฀be฀possible฀to฀make฀a฀correct฀judgment฀as฀to฀the฀means฀by฀ 216฀ ฀ ฀฀’฀฀฀฀ studying฀the฀type฀of฀treatment฀to฀be฀used,฀its฀degree฀of฀complexity฀or฀risk,฀its฀ cost฀and฀the฀possibilities฀of฀using฀it,฀and฀comparing฀these฀elements฀with฀the฀ result฀that฀can฀be฀expected,฀taking฀into฀account฀the฀state฀of฀the฀sick฀person฀and฀ his฀or฀her฀physical฀and฀moral...