Backgrounder: Confusion has marked debate over providing food and water

New York

Today’s ruling from the Congregation for the Doctrine of the Faith on providing food and water to patients in a persistent vegetative state, concluding that such care is always obligatory unless the patient can't assimilate the food or it causes significant physical discomfort, marks an attempt to bring clarity to an ethical debate which, up to now, has featured clashing and sometimes contradictory positions at senior levels of the church, especially in the United States.

Over the last two decades, the range of official responses to this question from within the American church has been remarkably broad. For example:

•tIn 1987, the bishops of New Jersey argued that removing food and water from severely brain-damaged patients was tantamount to starving them to death, and therefore morally unacceptable.
•tIn 1990, sixteen of the eighteen bishops in Texas took a more permissive stance. They concluded that patients in a persistent vegetative state “are stricken with a lethal pathology which, without artificial nutrition and hydra¬tion, will lead to death. . . . The morally appropriate forgoing or withdrawing of artificial nutrition and hydration from a permanently unconscious person is not abandoning that person. Rather, it is accepting the fact that the person has come to the end of his or her pilgrimage and should not be impeded from taking the final step.”
•tIn 1991, the bishops of Oregon and Washington issued a statement concluding that artificial nutrition and hydration can be withdrawn if it poses unreasonable burdens upon the patient.
•tIn 1992, the Committee for Pro-Life Activities of the U.S. bishops published a more restrictive statement: “We hold for a presumption in favor of providing medically assisted nutrition and hydration to patients who need it, which presumption would yield in cases where such procedures have no medically reasonable hope of sustaining life or pose excessive risks or burdens.”
•tAlso in 1992, the Catholic bishops of Pennsylvania struck a similar position. “As a general conclusion, in almost every instance there is an obligation to continue supplying nutrition and hydration to the unconscious patient,” the bishops concluded. “There are situations in which this is not the case [e.g., when the patient can no longer assimilate the food and its provision is hence useless], but these are exceptions and should not be made into the rule.”
•tIn 1995, the Ethical and Religious Directives issued by the United States bishops held in directive 58: “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.”
•tIn 2001, the bishops of Illinois issued a statement on dying that seemed to countenance the removal of feeding tubes under certain conditions: “For those who are suffering from metastatic cancer, end-stage congestive heart failure, or advanced Alzheimer's disease or other dementia, it is difficult to see any justification for resuscitation in the event of cardiac arrest or the prolonged use of intubation and mechanical ventilation,” they concluded.

Recent papal teaching has also created some degree of uncertainty. In March 2004, Pope John Paul II addressed a conference on patients in a persistent vegetative state organized by the Pontifical Academy for Life in Rome. The pope argued that the provision of food and water is always an “ordinary” means and therefore morally obligatory. In November of the same year, however, he delivered another allocution on the subject of palliative care, in which he said, “True compassion … encourages every reasonable effort for the patient’s recovery. At the same time, it helps draw the line when it is clear that no further treatment will serve this purpose.”

In the late 1980s, bioethics expert Thomas Shannon sent a questionnaire to bishops of American dioceses on the matter. Seventy-eight bishops responded, and the results indicated that directives on provision of food and water were quite different from diocese to diocese, and sometimes at odds with one another.

In light of that confusion, the request from the Committee on Doctrine to the Congregation for the Doctrine of the Faith is hardly surprising – especially given wrenching national debates in the United States in 2005 surrounding the case of Terry Schiavo, a Florida woman in a semi-comatose state who died in 2005 after a feeding tube that had kept her alive for 15 years was withdrawn.

One interesting wrinkle to today’s response from the Vatican is that the chair of the U.S. bishops’ Committee on Doctrine at the time its request for clarification was sent to Rome was Archbishop William Levada of San Francisco. Today, Cardinal Levada is the head of the Congregation for the Doctrine of the Faith, which means, in effect, that he was put in the position of answering his own question.

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