Medicine, Health Care, & Ethics: Catholic Voices

6. Medically Assisted Nutrition and Hydration in Medicine and Moral Theology - John Berkman

Chapter 6 Medically Assisted Nutrition and Hydration in Medicine and Moral Theology John Berkman For a significant portion of the 1980s, ethical issues regarding the use of various forms of support to prolong life grabbed newspaper headlines in the United States. High-profile legal cases over the “right to die,” such as those of Karen Ann Quinlan and Nancy Cruzan, became legal landmarks. Other highly publicized cases, such as those of Brophy, Conroy, Herbert, and Jobes, contributed to making the issue a commonplace part of the news. In the midst of the headlines generated by these and other related cases, many Catholic ethicists attempted to provide analysis and guidance. These cases also elicited frequent formal statements from the Catholic episcopacy, both from individual bishops and from episcopal conferences.1 Of the various ethical dilemmas surrounding decisions regarding the use of life support, none provoked more disagreement among both CathThis article originally appeared in The Thomist 68 (2004): 69–104. Thanks to Michael Baxter , Bill Mattison, Joyce McClure, Gilbert Meilaender, John Grabowski, and William Barbieri for helpful comments on earlier drafts of this paper. Thanks also to Jennifer Moore, M.D., and Heidi White, M.D., for insight on current medical practice with regard to MANH, and to Thomas Bender, M.D., for originally bringing to my attention the Kelly-Donovan debate. Finally , I wish to acknowledge with gratitude the support of the Duke Institute on Care at the End of Life, where I was Visiting Scholar in 2001–2, and where much of the research for this paper was conducted. 143 olic ethicists and the Catholic episcopacy than that of the use of medically assisted nutrition and hydration (henceforth MANH). Among the episcopacy , this disagreement gained a high profile in statements from the Texas and Pennsylvania bishops, as well as those of other groups of bishops. There were regular if not constant exchanges between Catholic ethicists on this question through the 1980s and early 1990s.2 The literature detailing various arguments for or against the use of MANH in caring for the dying and debilitated is extensive. Yet the thesis of this article is that a large part, if not the main thrust, of the debates over MANH has been inadequate and misguided on a number of different levels . I hope to reorient and redirect the debate by attending to the medical history of MANH (part 1) and recent medical developments with regard to MANH (part 5), examining and contextualizing the earliest debate (i.e., in the 1950s) over MANH among moral theologians (part 2) as well as a more recent debate over MANH involving numerous American Catholic bishops (part 3), and critically evaluating the types of moral arguments that preoccupy many of those who currently write on the ethics of MANH (part 4). The first section—a brief history of nineteenth- and twentieth-century medical practice with regard to MANH—aims to show that inadequate understanding of the medical history, development, and varying roles of medically assisted nutrition and hydration has led moralists to overly rigid understandings of its place in medicine. One upshot of what I argue in this section is that, for example, attempts to define MANH as either inherently “basic care” or “a medical treatment” is an exercise in futility. Such descriptions are only legitimate in specific medical contexts and are “patient dependent.” With this history providing a sense of the medical context of MANH in the 1950s, the second section analyzes what I believe is the first discussion of MANH by American moral theologians, placing it in the context of their broader concern with “the duty to preserve life.” The astute reader will surmise that the very different medical context for MANH at that time reveals both the achievement and the limitations and provisional character of the debate over MANH by the Catholic moralists (e.g., Gerald Kelly, S.J.) of that era. In view of the evolving medical context of MANH between the 1950s and the 1980s, one goal of this section is to show the problematic nature of appeals by some later Catholic moralists to the authority of earlier authors on the question of MANH. The third section examines a more recent Catholic “debate”—one between two groups of American Catholic bishops in the early 1990s—over 144 john ber kman the appropriate uses of MANH. Even this relatively recent debate cannot be separated from its specific social and medical context...