ON March 20, Pope John Paul II addressed doctors, palliative care specialists, lawyers and ethicists meeting in Rome for a conference entitled ‘Life Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas’.
In his address, the Pope spoke of the obligation to provide nutrition and hydration to patients who are commonly said to be ‘in a persistent vegetative state (PVS)’.
In view of the debates over this question in recent years, the Pope’s reflections and teachings are much to be welcomed by Catholic health care professionals.
This briefing note explains the background and context for the Pope’s statement, the key points made by the Pope, and the implications of his statement for Catholic health care professionals in Australia.
Background and context
As stated in the CHA [Catholic Health Australia] Code of Ethical Standards, life sustaining treatments are not obligatory when they are therapeutically futile or when they impose an undue burden on the patient and/or others, including the patient’s family and the available health care resources (1.13; 5.9-5.12).
The application of this principle to PVS patients has been much debated by Catholic ethicists.
These patients have suffered either a traumatic injury, a non-traumatic episode (eg stroke) or are suffering from a degenerative disease, and have emerged from coma into a cycle of wakefulness and sleep.
They remain unresponsive to most stimuli, are apparently unconscious and have usually lost the swallowing reflex.
The NHMRC [National Health and Medical Research Council] has proposed that such patients be described as ‘post coma unresponsive’.
Although many such patients either die or emerge from their unresponsive state within a few months, some can live for several years if they are provided with nutrition and hydration.
The Catholic ethical debate has centred on whether maintaining the life of such patients via a nasogastric or a PEG tube or intravenously or subcutaneously is a legitimate and/or obligatory goal, given the patient’s seeming lack of conscious awareness and the unlikelihood of ever recovering greater function.
There has also been debate about whether such ‘artificial’ feeding is or is not a ‘medical treatment’, such as would be not obligatory under legislation in some states in Australia.
Although the immediate context for the Pope’s remarks was a conference on the vegetative state, similar ethical questions arise in the case of other patients, eg those suffering from advanced dementia, severe stroke, advanced metastases or advanced neurogenic disease.
Hence, the Pope’s speech is of wide relevance to Catholic health care professionals.
In addressing these issues in the form of an allocution to a gathering of health care professionals, the Pope has followed the example of his recent predecessors who used similar contexts for the exercise of their ordinary authority to speak on ethical issues.
Key points made by the Pope
The Pope made a number of points that must now inform Catholic ethical reflection.
First, the Pope criticised the application of the term ‘vegetative’ to any human being.
Whatever its medical significance, this term when used by ordinary people tends to obscure the humanity of the patient, who always remains a living human person, with all the dignity and rights of a human person. (Happily, this point has also been made by the Australian NHMRC, in its advocacy of the term ‘post-coma unresponsiveness’.)
Secondly, the Pope stated that the provision of nutrition and hydration, even when provided by artificial means such as a naso-gastric or PEG tube, should be viewed as a ‘natural’ means of care and not as a medical procedure or treatment.
Thirdly, the Pope said that the provision of nutrition and hydration, even by artificial means, should be considered in principle to be ordinary and proportionate and, as such, morally obligatory, as long as it gives nourishment and/or relief from suffering.
Fourthly, in saying that the provision of nutrition and hydration is in principle obligatory, the Pope allows for those cases in which the provision of nutrition and hydration would not be appropriate, either because they would not be metabolised adequately, or because their mode of delivery would be gravely burdensome.
Fifthly, the Pope notes that to cease providing nutrition and hydration that is neither futile, nor unduly burdensome, with a view to shortening a patient’s life, would be euthanasia by omission.
Implications of the Pope’s statement
The recent CHA Code of Ethical Standards is in accord with these teachings by the Pope.
Sections 5.9-5.11 explain why there should be a presumption in favour of providing life-sustaining measures to all patients.
However, in the light of the Pope’s statement, the following points deserve further emphasis.
The fact that a patient remains unresponsive after emerging from coma, and irrespective of how long the patient remains in this state, does not mean that the patient is any less deserving of medical treatment and non-medical care.
Such patients should not be abandoned nor denied ordinary care and life-sustaining measures.
In all cases, the judgments about the care due to patients should be based on the relevant medical and ethical criteria, not on the quality of the patient’s life or state of consciousness.
The provision of food and water, even by artificial means, is not in itself a medical treatment that may be forgone or withdrawn solely on the grounds that it is a medical treatment (as was implied by the BWV case in Victoria in 2003).
In itself, the provision of food and water (by whatever means) is the ordinary way of sustaining a patient’s life and a minimal part of the care we owe to others.
Accordingly, there is always a presumption that nutrition and hydration be provided to a patient, unless this would be futile or unduly burdensome (see CHA Code 1.13-1.14).
In particular cases, however, the provision of nutrition and hydration may cease to be obligatory, eg if the patient is unable to assimilate the material provided or if the manner of the provision itself causes undue suffering to the patient, or involves an undue burden to others.
As the CHA Code notes, in Australia tube feeding is not normally too burdensome to others (5.12).
The Pope’s statement does not explore the question whether artificial feeding involves a medical act or treatment with respect to insertion and monitoring of the feeding tube.
While the act of feeding a person is not itself a medical act, the insertion of a tube, monitoring of the tube and patient, and prescription of the substances to be provided, do involve a degree of medical and/or nursing expertise.
To insert a feeding tube is a medical decision subject to the normal criteria for medical intervention.
Whenever medical treatment or the provision of nutrition and hydration is withheld or withdrawn for legitimate reasons (futility, burdensomeness), this is not euthanasia.
As the Pope wrote in Evangelium Vitae, ‘Euthanasia must be distinguished from the decision to forgo … medical procedures which no longer correspond to the real situation of the patient, either because they are by now disproportionate to any expected results or because they impose an excessive burden on the patient and his family … To forgo extraordinary or disproportionate means is not the equivalent of suicide or euthanasia; it rather expresses acceptance of the human condition in the face of death’ (EV 65).
In summary, the Pope’s statement is an application of traditional Catholic teaching, and says neither that nutrition and hydration must always be given, nor that they are never to be given, to unresponsive and/or incompetent patients.
Rather, the Pope affirms the presumption in favour of giving nutrition and hydration to all patients, even by artificial means, while recognising that in particular cases this presumption gives way to the recognition that the provision of nutrition and hydration would be futile or unduly burdensome.