ON ENDING LIFE-SUPPORT

Two recent cases illustrate the difficulty – and often the agony – experienced by family members and medical teams when they have to decide whether or not to remove life-support from an apparently dying patient.

This past July a twenty-six year old man was reportedly placed on life-support following an automobile accident. He was in a coma for two weeks and remains so at this writing. Physicians treating him at the University of Virginia Medical Center wanted to remove him from life-support, deeming the case hopeless. The young man’s father, however, secured a court order prohibiting the medical team from doing so, in the hope that his son would recover.

The case raises issues regarding the allocation of available resources, as well as the so-called burden-benefit calculus: can the life-support technology be better used elsewhere, and is the man’s prognosis so poor that continued support would be futile, merely drawing out the dying process with no chance of restoring life?

On both counts the father certainly didn’t think so. Was he acting out of responsible conviction (and perhaps faith)? Or was his opposition to the doctors’ decision based on empty hope that merely reflected his grief at the prospect of losing his son?

A second case is far more striking. For nineteen years following a truck crash in 1984, Terry Wallis was paralyzed. At first comatose, he drifted into what is termed a “persistent vegetative state” (PVS). This is characterized by periods of apparent wakefulness, with open eyes and emitted sounds, although the person is unresponsive to stimuli, such as the voice of a family member. Very few people survive PVS. So the question arises: should such patients be maintained – often for years – on life-support, including food and hydration, or should they be removed and allowed (i.e., compelled) to die?

The question was answered when Terry Wallis, on June 11 of this year, emerged from his inner imprisonment and spoke to his mother. A simple regimen of anti-depressants seems to have improved his condition dramatically, to the point that he is now on the way to full recovery.

In today’s atmosphere, aptly characterized as “a culture of death,” there is increasing pressure on families and on medical professionals to remove life-support in such cases. On the other hand, fear of a lawsuit for “unlawful death” prompts some medical teams to continue life-support where it is clearly not in the best interest of the patient. It has been shown, for example, that when a person is in a truly terminal state – that is, when “the soul is struggling to leave the body,” and death is imminent – removing a feeding tube and even withholding hydration can be beneficial. (Artificially introducing food and water into the patient’s system prevents the build-up of natural analgesics. It keeps the cellular system “alive” and merely draws out the terminal phase, thus hindering the “peaceful separation of soul and body” that we request in the Church’s prayer.)

How do we discern the just, appropriate and good decision in this regard? That is, how do we discern the will of God in cases where someone close to us is on life-support and judged to be “terminally” ill?

As so often in the moral life, there is no pat answer, no simple reply that fits every case. A rule of thumb should be obvious, however. Where the patient is comatose or in PVS, the diagnosis should never be “terminal.” There is a vast difference between withdrawing or withholding life-support from such a person on the one hand, and on the other, from someone who, in the judgment of the medical team, is irreversibly engaged in the “dying process.” While the dying person might well benefit from no treatment, thereby allowing death to occur naturally, withholding life-support from a comatose or PVS patient amounts to a death sentence. Terry Wallis’ mother was certain she could convey love to her son and evoke a similar response on his part. Her conviction was confirmed, as he spoke his first word in nineteen years: “Mom.”

As for those who are truly “terminal,” any decision to withhold or withdraw life-support needs to be made between family members (or other proxies) and the medical staff. This may require seeking the counsel of local clergy, the hospital chaplain or ethics advisor, particularly where the patient has not left advance directives. And, as many of us have experienced, it may also lead to disagreements and bitter disappointment, compounded by the weight of guilt and grief.

This likelihood underscores the most basic need, which is to place the dying person in the hands of God through our ongoing intercession. Death is not a private matter. It involves family, Church and other forms of community that have engaged and sustained the person over the years. Insofar as it does involve the Church, it is our responsibility and our privilege to journey with the dying person and his or her loved ones, to pray God’s healing grace and mercy upon them all, and finally to surrender the person into His care.

As Christian people, any decision on our part to end life-support measures can only be justified – can only be considered good, right and appropriate – insofar as together, as the Church, we intend to accompany the dying person step by step through the terminal stage, and entrust that person, through our prayer and gestures of compassion, into the loving embrace of the Author of Life.

One more from Fr. Breck.

"May 2004 Article #1 - CARE FOR PATIENTS IN "PVS"
By Fr John Breck

On March 20 of this year Pope John-Paul II addressed a gathering of physicians and theologians on the issue of care for patients in a chronic or persistent "vegetative state" (pVS). This is a condition, often referred to as "brain death," brought on by severe damage to the cerebral hemispheres. It leaves the patient with no capacity for selfawareness or ability to relate to others. Since the brainstem is intact, however, autonomic and motor reflexes function normally. The patient experiences ordinary sleep-wake cycles and often emits sounds that can be misunderstood as attempts to speak. Where this so-called vegetative state has persisted for more than a few months, there are no documented cases of full recovery. (The term "vegetative" refers to the condition; it does not imply that the patient is less than human or is no longer a "person" in the full sense.)

The Pope was responding, at least in part, to the much-publicized case of Terri Schiavo, a brain-damaged patient whose husband has sought to have her feeding tube removed. Although she has been diagnosed .as being in a "vegetative" state, this has yet to be clearly demonstrated. The rule of thumb should be that where there is doubt, nutrition and hydration should definitely be continued. In cases of actual PVS, removal of nutrition and hydration leads quickly to death. Many ethicists argue that such removal is morally acceptable, since the underlying cause of death is the irreversible medical condition that prevents the patient from taking food normally.

Since the early 1980s it has been clinically established that withholding food and hydration from terminally ill patients - that is, those who are actively engaged in the dying process - can be beneficial. It allows the build-up of nitrogen wastes that produce azotemia, a natural analgesic, and can enable the patient to slip into a coma and die peacefully. On the other hand, continuing to provide food and water through intubation in terminal cases can increase the patient's sense of pain and suffering, without offering a proportional benefit.

The question raised by the Schiavo case, as by the Pope's declaration, is whether it is ever morally and medically appropriate to remove food and hydration from a patient in PVS. Such patients are not, in the strict sense, terminally ill; that is, they are not actually dying, even where there is no chance for recovery. If they are provided with food and water, they can live for months or even years. Yet their physical existence is preserved only by life-support technology and they remain in a state of permanent unconsciousness. If that technology were not available, such patients would quickly die, since they are incapable of feeding themselves or of being fed orally.

Catholic moral theologians have long debated whether providing nutrition and hydration to patients in PVS falls into the area of "ordinary" or "extraordinary" means. If the former, then such treatment is ethically mandatory; if the latter, then, weighing burdens against benefits, it may be morally appropriate to withdraw all life-support and allow the patient to die. The Pope's declaration made it clear that he locates the providing of food and water in the realm of ordinary means, and therefore it is morally obligatory in cases of PVS. Many Catholic ethicists, however, feel otherwise. They argue that there comes a point in a person's life where administering artificial nutrition and hydration merely hinders the patient from attaining what we request in our Orthodox prayers: a "peaceful separation of soul and body," "a painless, blameless and peaceful" end to earthly life and the passing on of the person to the ultimate end of human existence, which is eternal communion with God in the Kingdom of Heaven.

In light of those prayers and the Orthodox perspective on the mystery of death, we need to have as our primary concern the best interests of the patient. No one wants to lose a beloved mend or family member. Accordingly, there is a strong temptation (and often pressure) to do "all possible" to ward off death, even if it means preserving a minimal level of existence by purely artificial means. We need to ask, though, whether such actions serve the interests and well-being of the patient, or whether they derive from our own reluctance to accept the loss associated with death and to surrender the person into the hands of God.

This raises the question of the "quality" of the patient's life. Often the decision to provide or withhold nutrition and hydration is made on the basis of a subjective judgment as to whether the patient's existence is worth preserving. The issue has unfortunately been polarized between those who argue for "sanctity of life" criteria (life is inherently sacred, therefore it must be preserved at all costs) and those who argue for "quality" considerations (if that life is deemed worthless or pointless, then there is no obligation to preserve it).

This way of raising the question, however, is false and misleading. All human life is inherently sacred, and it is precisely that sacredness that invests it with its ultimate and indelible "quality." This means, however, "there is a time to live and a time to die." Death in a biblical perspective - a Paschal perspective - is no longer "the last enemy." Death itself has been destroyed, and "we are given Life." From the time of our conception until the end of our physical existence, the very purpose of our being is to allow the Holy Spirit to work within us the transformation from a "body of death" to "life in Christ," a life that begins in the present age and endures through and beyond physical death, into the fullness of life in the Kingdom God.

When a person is dying - when "the soul is struggling to leave the body" - then, again, it may be morally permissible, even obligatory, to withhold nutrition and hydration, in order that death may come "naturally," as a regretted end but a blessed beginning to a new order of life. Can we say the same of patients in PVS, who, technically, are not "terminal"?

All we can conclude, it seems, is this. Where there is no chance for recovery other than through God's own miraculous intervention (which can occur at any point), then it seems reasonable to conclude that artificial means of life-support, including nutrition and hydration, may be morally withdrawn or withheld. The final judgment needs to be made, not by distinguishing "ordinary" from "extraordinary" means, but by weighing the possibilities for cure. Where further medical intervention is futile, and merely hinders the person in his or her struggle to die, then such intervention should be judged to be abusive rather than beneficial. "Medical heroics" in such a case are morally inappropriate.

Yet any decision to remove life-support, particularly in non-terminal cases such as PVS, must be taken as the fruit of ardent and "disinterested" prayer. This does not mean that we should expect that an answer to the question regarding appropriate treatment or non-treatment will be written on the wall. It means that members of the Church community - including the family, friends, and insofar as possible the medical team offer the patient to God through ceaseless intercession, asking for both clarity and charity in making what could be their final decision regarding that patient's future and well-being. In the final analysis, everything depends on our motive. Where our primary concern is for the ultimate healing and salvation of the person in question, then we can make decisions, even in a state of uncertainty and confusion, with the confidence that God, in His time and in His way, will indeed work for that person the paschal miracle that leads from a "dying life" through physical death, and into Life beyond.

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