Are Persons In The 'Vegetative' State Dying? Is Feeding Them By Tubes Morally Repugnant?

March 25, 2010 09:00 AM

(Part two of a two-part guest commentary by William E. May, Ph.D.)

In yesterday’s commentary, I noted that many elderly people, when interviewed by the Chicago Tribune, were horrified at the thought of lingering unconsciousness. As one of them said, “My pleasure is in being part of the human race. If that’s gone, if I can’t interact with other people, even if they could give me nutrition and keep me hydrated, I’m not interested in being preserved.” I also noted that for many years I shared this point of view and thought that using various tubes to feed and hydrate permanently unconscious persons, i.e., those in the “permanent vegetative state,” was morally repugnant and imposed cruel burdens on them and their families.

Thus in a book published in 1977, Human Existence, Medicine and Ethics: Reflections on Human Life, I claimed, in commenting on the celebrated case of Karen Ann Quinlan, that there was no obligation “to use the means currently employed to prolong her death” and that it would be morally permissible for her parents and others to “remove the tubes necessary for her feeding, prevent dehydration by appropriate medical means, and attend to her in her dying moments” (pp. 150-51). But in 1985, a study group of the Pontifical Academy of Sciences released a report on this matter and in its “Medical Guidelines” declared: “If the patient is in a permanent, irreversible coma, as far as can be foreseen, treatment is not required, but all care should be lavished on him, including feeding” (emphasis added). This made me begin to reconsider the position I had taken in 1977.

In 1986, Rev. William Gallagher, then president of the Pope John XXIII Center (now the National Catholic Bioethics Center), asked me to gather a group of moral theologians, philosophers, lawyers, medical doctors and nurses to study the issues involved in providing food and hydration to the permanently unconscious and other vulnerable persons. I succeeded in getting the following persons to meet at the Catholic University of America once a week for six weeks: Benedict Ashley, O.P., Robert Barry, O.P., Msgr. Orville Griese, Germain Grisez, Brian Johnstone, C.Ss.R., Thomas Marzen, J.D., Bishop James McHugh, S.T.D., Gilbert Meilaender, Ph. D., Mark Siegler, M.D. and Msgr. William Smith. Some nurses who had spent hours caring for “vegetative” patients attended some sessions and made us aware of their experience.

PVS patients are not dying or in danger of imminent death

Reflections from Dr. Siegler, study of relevant medical literature and the testimony of the nurses taught the theologians, philosophers and lawyers of our group that individuals in this condition are not suffering from a “fatal” pathology, as some theologians claimed. Rather, they are in a relatively stable condition and can live an indefinite period of time so long as they receive food and hydration. If they are not fed, they die of starvation and dehydration. We also learned that at the beginning they are capable of swallowing; however, feeding them orally is time-consuming and the use of tubes to feed them lightens the burdens of their caregivers; as this continues, their ability to swallow atrophies. We also learned that the cost of feeding them is minimal—more money is spent on pet food than on the nutrition these persons need. Moreover, they do not have to be kept in expensive institutions but can be cared for at home if there is someone there to provide care who can be helped by visiting nurses, etc. I learned from one of my students that his brother, alleged to be “vegetative,” was in fact being cared for in his home by his mother and siblings. Some 20 years later, I was informed recently, this student’s brother regained consciousness and was delighted then to be home with his loved ones who had given him such loving care.

As a result of this new knowledge, based on medical and scientific studies and not on the opinions of theologians, two of us (Germain Grisez and I) changed our minds. Prior to these meetings we had thought—and taught—that tubally providing such persons with food and nutrition was not morally appropriate because it was relatively useless and unduly burdensome. All those who took part in our meetings and discussions—with one exception—collaborated in writing an essay listing me as principal author, “Feeding and Hydrating the Permanently Unconscious and Other Vulnerable Persons” and published in Issues in Law & Medicine, Vol. 3, No. 2 in 1987. The essay concluded:

[I]n the ordinary circumstances of life in our society today, it is not morally right, nor ought it to be legally permissible, to withhold or withdraw nutrition and hydration provided by artificial means to the permanently unconscious or other categories of seriously debilitated but nonterminal persons. Rather, food and fluids are universally needed for the preservation of life, and can generally be provided without the burdens and expense of more aggressive means of supporting life. Therefore, both morality and law should recognize a strong presumption in favor of their use (p. 211).

Benedict Ashley, another member of the group who had previously judged it not morally required to provide food and hydration by tubal means, did not change his mind and accordingly did not sign this document. Here I will not give all the reasons he and his colleague Kevin O’Rourke, O.P. used to justify their conclusion that there was no moral obligation to preserve the lives of the “permanently unconscious” by feeding them tubally. [1] One of their major reasons, however, was that permanently unconscious persons are suffering from a fatal pathology. But, as we have seen, medical scientists disagree with them here.

The issue debated

From the 1980s through the rest of the twentieth century there was a vigorous debate among authorities, Catholic and otherwise, over the proper moral way to treat patients in the “vegetative” state. In fact, Catholic bishops disagreed on the matter, as did theologians, philosophers, and bioethicists, whether Catholic or non-Catholic. Thus, for instance, the Texas Conference of Catholic Bishops issued a pastoral letter in May 1990, claiming that there is no moral obligation to feed and hydrate such persons because this treatment is burdensome and futile (“On Withdrawing Artificial Nutrition and Hydration,” May 7, 1990, in Origins: NC News Service 20 (1990) 53-55). However, the Committee for Pro-Life Activities of the NCCB issued a document in 1992, “Nutrition and Hydration: Moral and Pastoral Reflections” in Origins: NC News Service 21 (1992) 705-711. In it, they said: “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.” John Paul II singled out this statement for praise in a talk to a group of U.S. bishops on their ad limina visit to the Vatican in 1998. The Pennsylvania Conference of Catholic Bishops issued a lengthy document, filled with references to medical literature, “Nutrition and Hydration: Moral Considerations,” in Origins: NC News Service 21, 542-553, in 1992 that was similar to that of the Committee for Pro-Life Activities. In it they wrote: “As a general conclusion, in almost every instance there is an obligation to continue supplying nutrition and hydration to the unconscious patient. 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.” In their judgment, artificially providing food to PVS patients is “clearly beneficial in terms of preservation of life,” nor does it, in almost every case, add a “serious burden.” Consequently, it is morally obligatory.

John Paul sought to end this debate with his “Address to Participants in the International Congress on ‘Life-Sustaining Treatments and the Vegetative State: Scientific Advance and Ethical Dilemmas.’” [2] His address was shaped by the scientific papers given at that Congress, which showed that persons alleged to be vegetative were frequently misdiagnosed and that some gave incontrovertible evidence that they were conscious and aware. John Paul held that feeding and hydrating them tubally is morally required unless one can show that doing so is futile and unduly burdensome. His address was defended vigorously in a 2007 document of the Congregation for the Doctrine of the Faith, which included a remarkable commentary. [3] Although some theologians repudiate his teaching, [4] scientific studies and sound moral reasoning support it.

Notes

[1] I summarize and criticize the criteria Ashley and O’Rourke use for distinguishing between ordinary/proportionate (morally required) and extraordinary/disproportionate (not required) and their application of these criteria to the tubal feeding of the “vegetative” in “Catholic Bioethics and the Gift of Human Life” (2nd ed.: Huntington, IN: Our Sunday Visitor, 2003), pp. 278-280 and 288-291.
[2] Pope John Paul II’s address is accessible at http://www.vatican.va/holy_father/john_paul_ii/speeches/2004/march/documents/hf_jp-ii_spe_20040320_congress-fiamc_en.html .
[3] The Congregation’s document, “Responses to Certain Questions of the United States Conference of Catholic Bishops Concerning Artificial Nutrition and Hydration,” is accessible at http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_20070801_risposte-usa_en.html . Its remarkable commentary is accessible at http://wf-f.org/CDF_Nutrition&Hydration.html .
[4] Several Catholic bioethicists, among them Lisa Cahill, James Walter, Thomas Shannon and John Tuohey strongly took John Paul to task, claiming his teaching was not in harmony with traditional Catholic principles and that it imposed cruel burdens on people. I show how wrong these claims are in Catholic Bioethics, pp. 292-296.

This article is reprinted with permission from the Culture of Life FoundationCLF is a social policy research institute that exists to reveal and present the truths about the human person at all stages of life and in all conditions.

Dr. William E. May 
is senior research fellow of CLF and emeritus Michael J. McGivney professor of moral theology at the John Paul II Institute for Studies on Marriage and Family in Washington, D.C. He taught at the John Paul II Institute from 1991 through 2008, after teaching for 20 years at the Catholic University of America. He is the author of more than a dozen books and is married to Patricia Keck May. They are the parents of seven children and the grandparents of 14 grandchildren, with more, God willing, anticipated in the future.

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