Posted on 03/25/2005 5:01:12 PM PST by Wolfstar
Karen Ann Quinlan was the first modern icon of the right-to-die debate. The 21-year-old Quinlan collapsed at a party after swallowing alcohol and the tranquilizer Valium on April 14, 1975. Doctors saved her life, but she suffered brain damage and lapsed into a persistent vegetative state.
Karen Ann Quinlan
A dispute arose between the hospital officials and Karen’s parents about whether or not she should be removed from her respirator. Karen’s parents did not want to take extraordinary means to keep Karen alive; however, the hospital officials disagreed and wanted to keep her alive. The Quinlans believed that they had the right to legal guardianship for Karen. This led to two court cases involving who should become Karen’s legal guardian.
Her family waged a much-publicized legal battle for the right to remove her life support machinery. The Quinlans lost the first court case at the U.S. Supreme Court, but were victorious in New Jersey’s Supreme Court. This decision gave Joseph Quinlan, Karen’s father, legal guardianship over Karen. As a result, the Quinlan family decided to remove Karen from her respirator and the physicians obliged.
Unexpectedly, Karen continued breathing and was moved to Morris View Nursing Home where she lived for 10 years. She passed away on June 11, 1985.
The New Jersey Supreme Court Ruling became a precedent case for ethical dilemmas involving right-to-die cases in two significant ways. First, this case led to the requirement that all hospitals, hospice, and nursing homes have ethics committees. Second, it led to the creation of advance directives, in particular the living will.
Nancy Cruzan
The way Nancy's family engraved her headstone
Like Karen Ann Quinlan, Nancy Cruzan became a public figure after entering a persistent vegetative state. A 1983 auto accident left Cruzan permanently unconscious and without any higher brain function, kept alive only by a feeding tube and steady medical care. Cruzan's family waged a legal battle to have her feeding tube removed. The case went all the way to the U.S. Supreme Court, which ruled that the Cruzans had not provided "clear and convincing evidence" that Nancy Cruzan did not wish to have her life artificially preserved. The Cruzans later presented such evidence to the Missouri courts, which ruled in their favor in late 1990. The Cruzans stopped feeding Nancy in December of 1990, and she died later the same month.
Much has changed in the years since Nancy's death. The federal government passed a law requiring all persons entering a hospital in the United States be told about living wills. Most states have laws governing advance directives, durable powers of attorney and health care proxies.
Now, nearly 30 years to the day that Karen Quinlan collapsed, we have the Terri Schiavo case making headlines. In the intervening 30 years much precedent has been set and much case law has been settled in the so-called right-to-die area. Estimates are that some 30,000-35,000 people in the United States are currently in similar or identical states as Terri Schiavo, yet we do not hear about them. Life support measures -- including feeding tubes -- are removed virtually daily. Yet we do not hear about those cases. Why? Because the only thing unique about the Schiavo case is the epic family feud propelling it into the headlines.
People who so passionately argue for Schiavo to be saved have nothing to say about all the other similar or identical cases. Why? If one believes that all life must be saved, then why fight only for this single life?
I for one like to see some of these "thousands of cases out there" where the husband says pull the plug and the birth family says please don't we will take care of her?
You proved my point.
There may be a large number in a PSVT, but the numbers are from "Stroke" statistics.
The vast majority of strokes occur in elderly people with cardiovascular disease.
You are making an invalid comparison.
I want back up for the numbers that you are providing here and you can not seem to come up with even one court case.
All you have provided is a link to the WT that says that there are maybe 30,000 people in vegetative states. It does not say what kind of vegetative states they are in. It does not say that they are having their feeding tubes pulled to kill them. It does not say that they are otherwise healthy.
I repeat you are talking through your hat. Perhaps you should step back and quit being so emotionally involved with your position because frankly you are not producing many facts to back your suppositions up.
Yes.
Hey Ca Guy, I think we finally see the Democrats solution to the Social Security problem.
I can just hear ole mealy mouth now, We'll,a, a, a, use the final solution.
I for one "add" would!
You bet, just think how granny will be asked to take one for the family so her estate can pass on more intact than she would be?
Sorry, Wolfie, the "truth" is at issue, and is not as you and the other euthanasia enthusiasts have painted it.
I have read the statements. I have also read the statements from Vatican Officials that affirm that the removal of Terri's feeding tube violates Catholic teachings on Euthanasia and the Dignity of life.
Cardinal Sgreccia Noted that, “the removal of the gastric probe from her, in these conditions, could be considered direct euthanasia, because it is an integral part of the way in which Mrs Terri Schiavo can be fed and hydrated.
Statement of Cardinal Renato Martino,
President of the Pontifical Council for Justice and Peace
Vatican City
7 March 2005
The courts have ruled again and again. Unfortunately, the deadline for the removal of the tube delivering food and water to Terri Schiavo is quickly approaching. I am sorry to have to use the word “deadline” but this is the most accurate way to describe what will happen. Without the tube which is providing life-giving hydration and nutrition, Terri Schiavo will die. But it is not that simple. She will die a horrible and cruel death. She will not simply die; she will have death inflicted upon her over a number of terrible days, even weeks. How can anyone who claims to speak of the promotion and protection of human rights - of human life - remain silent? Is this not a question of the right to life? I believe that I must speak out about this in the same way that I would speak of the protection of the unborn and just as I would concerning any injustice.
And a statement by Pope John Paul II leaves no wiggle room.
In speaking about patients with PVS the Pope said.
Providing food and water to such patients should be considered natural, ordinary and proportional care - not artificial medical intervention, the Pope told members of the conference, which was organised by the World Federation of Catholic Medical Associations and the Pontifical Academy for Life.
"As such, it is morally obligatory," to continue such care, he said.
Since no one knows when a patient in a vegetative state might awaken, "the evaluation of the probability, founded on scarce hope of recovery after the vegetative state has lasted for more than a year, cannot ethically justify the abandonment or the interruption of minimal care for the patient, including food and water," he said.
I am looking at the broader issues.
Why you speak of that as if it's a bad thing, LOL
I know what the Vatican has said. I'm not disputing that. Merely pointing out that the Catholic Church itself cannot come to agreement on this matter. Obvious if you've read the link I've provided a few times now. Not obvious at all if you haven't read it, of course.
There are 2 points of view on this issue.
1) Humans have inherent value. Humans have a spark of God.
2) Humans are intelligent animals.They got here by accidents, they function as biologic machines, When they become unfixable throw them away.
I think we already did this in history one time. I don't want to do it again.
Again, your statistics are no good.
"TASMANIANRED wrote:
Frankly if there is any justice in this country at all, and I sincerely doubt it.
What should be done is to subpoena every hospital record on her.
The Physical Rhehabilation records, the Speech Pathology records, the swallowing studies should be examined in dept.
If there is indication that she was making progress, if she was swallowing at some point, then Michael Shiavo, Judge Greer, Felos should be prosecuted for entering into a criminal conspiracy to commit homicide.
That would reign in some judicial activism."
I totally agree.
It has happened before (murder).
Most of the wills and trusts in places like Beverly Hills have to have a clause that kids get nothing if they murder the parents. (Not a joke)
Where lots of money is involved, it gets even worse.
Before 1972, when influential neurologists Drs. Fred Plum and Bryan Jennett coined the term "persistent vegetative state" (PVS) to describe a condition in which a person was presumed awake but unaware because of an injury or illness involving the brain, the idea of removing a feeding tube from a brain-injured person was simply unthinkable. The experience of the Nazi euthanasia program -- which used medical personnel to end the lives of the disabled, mentally ill and others characterized as "useless eaters" -- was considered the ultimate betrayal of medical ethics and still fresh in many minds.
But around this same time, the euthanasia movement was finally gaining traction with its "living will" document, where a person could request no heroic measures when he or she was dying. Because traditional ethics held that medical treatment could be withheld or withdrawn if it was futile or excessively burdensome, there were few objections to such a document and state legislatures started passing laws giving legal status to such documents.
However, it wasn't long before "right to die" court cases involving people considered in PVS started to result in feeding tubes being withdrawn with the support and court testimony of some doctors and ethicists who maintained that PVS patients would never recover and that such patients would refuse medically assisted food and water. As a result, PVS began to be added to state "living will" laws and eventually such laws expanded to include documents allowing the withdrawal of virtually any kind of medical treatment or care by a designated surrogate when a patient was mentally unable to make decisions.
Some influential Catholic ethicists developed theological justifications for withdrawing food and water in the special case of PVS by arguing that there was no moral obligation to maintain the lives of such people who could supposedly no longer achieve the spiritual and cognitive purpose of life. Terms like "futile" and "burdensome" -- the traditional ethical standard for withdrawing treatment or care -- were redefined . "Futility" was now to mean little or no chance of mental not physical improvement, and "burdensome" to the patient, was extended to include family distress, medical costs and even social fairness in distributing "scarce health care resources".
Despite myriad Church statements supporting the basic right to food and water (see sidebar page 34), some of these Catholic ethicists even testified in "right to die" court cases that their view was consistent with Church teaching, insisting that there was no intention to cause death by starvation and dehydration but rather merely withdrawing unwanted and useless treatment.
Unfortunately, some Catholic ethicists have moved even beyond PVS, and now include conditions such as Alzheimer's and the newly named "minimally conscious state" (in which patients are mentally impaired but not unconscious) as additional circumstances in which giving a person medically assisted food and water, antibiotics, etc., is no longer obligatory.
http://www.ncbcenter.org/eol-guide-8.html
Euthanasia has been defined by Pope John Paul II, in The Gospel of Life, as "an action or omission which of itself and by intention causes death, with the purpose of eliminating all suffering." Supporters of euthanasia often justify it or physician-assisted suicide on the grounds that the pain of terminal illness is too great for the average person to bear. They hold that it is more merciful to kill the suffering patient. The Pope, as representative of Christ on earth, holds that "euthanasia is a grave violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person." It is a fundamentally unreasonable act.
Life-sustaining treatments and vegetative state: Scientific advances and ethical dilemmas. Address of John Paul II to the participants in the International Congress
http://www.lifeissues.net/writers/doc/doc_33vegetativestate.html
Well, since everyone else feels so free to post long articles vs. the more polite way of posting the link, let me post the article I am quoting from.
And let me ask this. What is the purpose of the Catholic Council of Bishops to develop policy like this if there is no intent for it to guide their membership? It clearly was meant for that so who do people listen to...the Bishops or the Vatican?
Questions about Medically Assisted
Nutrition and Hydration
In what follows we apply these well-established moral principles to the difficult issue of providing medically assisted nutrition and hydration to persons who are seriously ill, disabled or persistently unconscious. We recognize the complexity involved in applying these principles to individual cases and acknowledge that, at this time and on this particular issue, our applications do not have the same authority as the principles themselves.
Is the withholding or withdrawing of medically assisted nutrition and hydration always a direct killing?
In answering this question one should avoid two extremes.
First, it is wrong to say that this could not be a matter of killing simply because it involves an omission rather than a positive action. In fact a deliberate omission may be an effective and certain way to kill, especially to kill someone weakened by illness. Catholic teaching condemns as euthanasia "an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated." Thus "euthanasia includes not only active mercy killing but also the omission of treatment when the purpose of the omission is to kill the patient."[11]
Second, we should not assume that all or most decisions to withhold or withdraw medically assisted nutrition and hydration are attempts to cause death. To be sure, any patient will die if all nutrition and hydration are withheld.[12] But sometimes other causes are at work -- for example, the patient may be imminently dying, whether feeding takes place or not, from an already existing terminal condition. At other times, although the shortening of the patient's life is one foreseeable result of an omission, the real purpose of the omission was to relieve the patient of a particular procedure that was of limited usefulness to the patient or unreasonably burdensome for the patient and the patient's family or caregivers. This kind of decision should not be equated with a decision to kill or with suicide.
The harsh reality is that some who propose withdrawal of nutrition and hydration from certain patients do directly intend to bring about a patient's death, and would even prefer a change in the law to allow for what they see as more "quick and painless" means to cause death.[13] In other words, nutrition and hydration (whether orally administered or medically assisted) are sometimes withdrawn not because a patient is dying, but precisely because a patient is not dying (or not dying quickly) and someone believes it would be better if he or she did, generally because the patient is perceived as having an unacceptably low "quality of life" or as imposing burdens on others.[14]
When deciding whether to withhold or withdraw medically assisted nutrition and hydration, or other forms of life support, we are called by our moral tradition to ask ourselves: What will my decision do for this patient? And what am I trying to achieve by doing it? We must be sure that it is not our intent to cause the patient's death -- either for its own sake or as a means to achieving some other goal such as the relief of suffering.
Is medically assisted nutrition and hydration a form of "treatment" or "care"?
Catholic teaching provides that a person in the final stages of dying need not accept "forms of treatment that would only secure a precarious and burdensome prolongation of life," but should still receive "the normal care due to the sick person in similar cases."[15] All patients deserve to receive normal care out of respect for their inherent dignity as persons. As Pope John Paul II has said, a decision to forgo "purely experimental or ineffective interventions" does not "dispense from the valid therapeutic task of sustaining life or from assistance with the normal means of sustaining life. Science, even when it is unable to heal, can and should care for and assist the sick."[16] But the teaching of the Church has not resolved the question whether medically assisted nutrition and hydration should always be seen as a form of normal care.[17]
Almost everyone agrees that oral feeding, when it can be accepted and assimilated by a patient, is a form of care owed to all helpless people. Christians should be especially sensitive to this obligation, because giving food and drink to those in need is an important expression of Christian love and concern (Mt. 10:42 and 25:35; Mk. 9:41). But our obligations become less clear when adequate nutrition and hydration require the skills of trained medical personnel and the use of technologies that may be perceived as very burdensome -- that is, as intrusive, painful or repugnant. Such factors vary from one type of feeding procedure to another, and from one patient to another, making it difficult to classify all feeding procedures as either "care" or "treatment."
Perhaps this dilemma should be viewed in a broader context. Even medical "treatments" are morally obligatory when they are "ordinary" means--that is, if they provide a reasonable hope of benefit and do not involve excessive burdens. Therefore we believe people should make decisions in light of a simple and fundamental insight: Out of respect for the dignity of the human person, we are obliged to preserve our own lives, and help others preserve theirs, by the use of means that have a reasonable hope of sustaining life without imposing unreasonable burdens on those we seek to help, that is, on the patient and his or her family and community.
We must therefore address the question of benefits and burdens next, recognizing that a full moral analysis is only possible when one knows the effects of a given procedure on a particular patient.
What are the benefits of medically assisted nutrition and hydration?
According to international codes of medical ethics, a physician will see a medical procedure as appropriate "if in his or her judgment it offers hope of saving life, reestablishing health or alleviating suffering."[18]
Nutrition and hydration, whether provided in the usual way or with medical assistance, do not by themselves remedy pathological conditions, except those caused by dietary deficiencies. But patients benefit from them in several ways. First, for all patients who can assimilate them, suitable food and fluids sustain life, and providing them normally expresses loving concern and solidarity with the helpless. Second, for patients being treated with the hope of a cure, appropriate food and fluids are an important element of sound health care. Third, even for patients who are imminently dying and incurable, food and fluids can prevent the suffering that may arise from dehydration, hunger and thirst.
The benefit of sustaining and fostering life is fundamental, because life is our first gift from a loving God and the condition for receiving His other gifts. But sometimes even food and fluids are no longer effective in providing this benefit, because a patient has entered the final stage of a terminal condition. At such times we should make the dying person as comfortable as possible and provide nursing care and proper hygiene as well as companionship and appropriate spiritual aid. Such a person may lose all desire for food and drink and even be unable to ingest them. Initiating medically assisted feeding or intravenous fluids in this case may increase the patient's discomfort while providing no real benefit; ice chips or sips of water may instead be appropriate to provide comfort and counteract the adverse effects of dehydration.[19] Even in the case of the imminently dying patient, of course, any action or omission that of itself or by intention causes death is to be absolutely rejected.
As Christians who trust in the promise of eternal life, we recognize that death does not have the final word. Accordingly we need not always prevent death until the last possible moment; but we should never intentionally cause death or abandon the dying person as though he or she were unworthy of care and respect.
What are the burdens of medically assisted nutrition and hydration?
Our tradition does not demand heroic measures in fulfilling the obligation to sustain life. A person may legitimately refuse even procedures that effectively prolong life, if he or she believes they would impose excessively grave burdens on himself or herself, or on his or her family and community. Catholic theologians have traditionally viewed medical treatment as excessively burdensome if it is "too painful, too damaging to the patient's bodily self and functioning, too psychologically repugnant to the patient, too restrictive of the patient's liberty and preferred activities, too suppressive of the patient's mental life, or too expensive."[20]
Because assessment of these burdens necessarily involves some subjective judgments, a conscious and competent patient is generally the best judge of whether a particular burden or risk is too grave to be tolerated in his or her own case. But because of the serious consequences of withdrawing all nutrition and hydration, patients and those helping them make decisions should assess such burdens or risks with special care.
Here we offer some brief reflections and cautions regarding the kinds of burdens sometimes associated with medically assisted nutrition and hydration.
Physical risks and burdens
The risks and objective complications of medically assisted nutrition and hydration will depend on the procedure used and the condition of the patient. In a given case a feeding procedure may become harmful or even life-threatening. (These medical data are discussed at length in an Appendix to this paper.)
If the risks and burdens of a particular feeding procedure are deemed serious enough to warrant withdrawing it, we should not automatically deprive the patient of all nutrition and hydration but should ask whether another procedure is feasible that would be less burdensome. We say this because some helpless patients, including some in a "persistent vegetative state," receive tube feedings not because they cannot swallow food at all but because tube feeding is less costly and difficult for health care personnel.[21]
Moreover, because burdens are assessed in relation to benefits, we should ask whether the risks and discomfort of a feeding procedure are really excessive as compared with the adverse effects of dehydration or malnutrition.
Psychological burdens on the patient
Many people see feeding tubes as frightening or even as bodily violations. Assessments of such burdens are necessarily subjective; they should not be dismissed on that account, but we offer some practical cautions to help prevent abuse.
First, in keeping with our moral teaching against the intentional causing of death by omission, one should distinguish between repugnance to a particular procedure and repugnance to life itself. The latter may occur when a patient views a life of helplessness and dependency on others as itself a heavy burden, leading him or her to wish or even to pray for death. Especially in our achievement-oriented society, the burden of living in such a condition may seem to outweigh any possible benefit of medical treatment and even lead a person to despair. But we should not assume that the burdens in such a case always outweigh the benefits; for the sufferer, given good counseling and spiritual support, may be brought again to appreciate the precious gift of life.
Second, our tradition recognizes that when treatment decisions are made, "account will have to be taken of the reasonable wishes of the patient and the patient's family, as also of the advice of the doctors who are specially competent in the matter."[22] The word "reasonable" is important here. Good health care providers will try to help patients assess psychological burdens with full information and without undue fear of unfamiliar procedures.[23] A well-trained and compassionate hospital chaplain can provide valuable personal and spiritual support to patients and families facing these difficult situations.
Third, we should not assume that a feeding procedure is inherently repugnant to all patients without specific evidence. In contrast to Americans' general distaste for the idea of being supported by "tubes and machines," some studies indicate surprisingly favorable views of medically assisted nutrition and hydration among patients and families with actual experience of such procedures.[24]
Economic and other burdens on caregivers
While some balk at the idea, in principle cost can be a valid factor in decisions about life support. For example, money spent on expensive treatment for one family member may be money otherwise needed for food, housing and other necessities for the rest of the family. Here, also, we offer some cautions.
First, particularly when a form of treatment "carries a risk or is burdensome" on other grounds, a critically ill person may have a legitimate and altruistic desire "not to impose excessive expense on the family or the community."[25] Even for altruistic reasons a patient should not directly intend his or her own death by malnutrition or dehydration, but may accept an earlier death as a consequence of his or her refusal of an unreasonably expensive treatment. Decisions by others to deny an incompetent patient medically assisted nutrition and hydration for reasons of cost raise additional concerns about justice to the individual patient, who could wrongly be deprived of life itself to serve the less fundamental needs of others.
Second, we do not think individual decisions about medically assisted nutrition and hydration should be determined by macro-economic concerns such as national budget priorities and the high cost of health care. These social problems are serious, but it is by no means established that they require depriving chronically ill and helpless patients of effective and easily tolerated measures that they need to survive.[26]
Third, tube feeding alone is generally not very expensive and may cost no more than oral feeding.[27] What is seen by many as a grave financial and emotional burden on caregivers is the total long-term care of severely debilitated patients, who may survive for many years with no life support except medically assisted nutrition and hydration and nursing care.
The difficulties families may face in this regard, and their need for improved financial and other assistance from the rest of society, should not be underestimated. While caring for a helpless loved one can provide many intangible benefits to family members and bring them closer together, the responsibilities of care can also strain even close and loving family relationships; complex medical decisions must be made under emotionally difficult circumstances not easily appreciated by those who have never faced such situations.
Even here, however, we must try to think through carefully what we intend by withdrawing medically assisted nutrition and hydration. Are we deliberately trying to make sure that the patient dies, in order to relieve caregivers of the financial and emotional burdens that will fall upon them if the patient survives? Are we really implementing a decision to withdraw all other forms of care, precisely because the patient offers so little response to the efforts of caregivers? Decisions like these seem to reach beyond the weighing of burdens and benefits of medically assisted nutrition and hydration as such.
In the context of official Church teaching, it is not yet clear to what extent we may assess the burden of a patient's total care rather than the burden of a particular treatment when we seek to refuse "burdensome" life support. On a practical level, those seeking to make good decisions might assure themselves of their own intentions by asking: Does my decision aim at relieving the patient of a particularly grave burden imposed by medically assisted nutrition and hydration? Or does it aim to avoid the total burden of caring for the patient? If so, does it achieve this aim by deliberately bringing about his or her death?
Rather than leaving families to confront such dilemmas alone, society and government should improve their assistance to families whose financial and emotional resources are strained by long-term care of loved ones.[28]
What role should "quality of life" play in our decisions?
Financial and emotional burdens are willingly endured by most families to raise their children or to care for mentally aware but weak and elderly family members. It is sometimes argued that we need not endure comparable burdens to feed and care for persons with severe mental and physical disabilities, because their low "quality of life" makes it unnecessary or pointless to preserve their lives.[29]
But this argument -- even when it seems motivated by a humanitarian concern to reduce suffering and hardship -- ignores the equal dignity and sanctity of all human life. Its key assumption -- that people with disabilities necessarily enjoy life less than others or lack the potential to lead meaningful lives -- is also mistaken.[30] Where suffering does exist, society's response should not be to neglect or eliminate the lives of people with disabilities, but to help correct their inadequate living conditions.[31] Very often the worst threat to a good "quality of life" for these people is not the disability itself, but the prejudicial attitudes of others--attitudes based on the idea that a life with serious disabilities is not worth living.[32]
This being said, our moral tradition allows for three ways in which the "quality of life" of a seriously ill patient is relevant to treatment decisions:
Consistent with respect for the inherent sanctity of life, we should relieve needless suffering and support morally acceptable ways of improving each patient's quality of life.[33]
One may legitimately refuse a treatment because it would itself create an impairment imposing new serious burdens or risks on the patient. This decision to avoid the new burdens or risks created by a treatment is not the same as directly intending to end life in order to avoid the burden of living in a disabled state.[34]
Sometimes a disabling condition may directly influence the benefits and burdens of a specific treatment for a particular patient. For example, a confused or demented patient may find medically assisted nutrition and hydration more frightening and burdensome than other patients do because he or she cannot understand what it is. The patient may even repeatedly pull out feeding tubes, requiring burdensome physical restraints if this form of feeding is to be continued. In such cases, ways of alleviating such special burdens should be explored before concluding that they justify withholding all food and fluids needed to sustain life.
These humane considerations are quite different from a "quality of life" ethic that would judge individuals with disabilities or limited potential as not worthy of care or respect. It is one thing to withhold a procedure because it would impose new disabilities on a patient, and quite another thing to say that patients who already have such disabilities should not have their lives preserved. A means considered ordinary or proportionate for other patients should not be considered extraordinary or disproportionate for severely impaired patients solely because of a judgment that their lives are not worth living.
In short, while considerations regarding a person's quality of life have some validity in weighing the burdens and benefits of medical treatment, at the present time in our society judgments about the quality of life are sometimes used to promote euthanasia. The Church must emphasize the sanctity of life of each person as a fundamental principle in all moral decisionmaking.
Do persistently unconscious patients represent a special case?
Even Catholics who accept the same basic moral principles may strongly disagree on how to apply them to patients who appear to be persistently unconscious -- that is, those who are in a permanent coma or a "persistent vegetative state" (PVS).[35] Some moral questions in this area have not been explicitly resolved by the Church's teaching authority.
On some points there is wide agreement among Catholic theologians:
An unconscious patient must be treated as a living human person with inherent dignity and value. Direct killing of such a patient is as morally reprehensible as the direct killing of anyone else. Even the medical terminology used to describe these patients as "vegetative" unfortunately tends to obscure this vitally important point, inviting speculation that a patient in this state is a "vegetable" or a subhuman animal.[36]
The area of legitimate controversy does not concern patients with conditions like mental retardation, senility, dementia or even temporary unconsciousness. Where serious disagreement begins is with the patient who has been diagnosed as completely and permanently unconscious after careful testing over a period of weeks or months.
Some moral theologians argue that a particular form of care or treatment is morally obligatory only when its benefits outweigh its burdens to a patient or the care providers. In weighing burdens, they say, the total burden of a procedure and the consequent requirements of care must be taken into account. If no benefit can be demonstrated, the procedure, whatever its burdens, cannot be obligatory. These moralists also hold that the chief criterion to determine the benefit of a procedure cannot be merely that it prolongs physical life, since physical life is not an absolute good but is relative to the spiritual good of the person. They assert that the spiritual good of the person is union with God, which can be advanced only by human acts, i.e., conscious, free acts. Since the best current medical opinion holds that persons in the persistent vegetative state (PVS) are incapable now or in the future of conscious, free human acts, these moralists conclude that, when careful diagnosis verifies this condition, it is not obligatory to prolong life by such interventions as a respirator, antibiotics, or medically assisted hydration and nutrition. To decide to omit non-obligatory care, therefore, is not to intend the patient's death, but only to avoid the burden of the procedure. Hence, though foreseen, the patient's death is to be attributed to the patient's pathological condition and not to the omission of care. Therefore, these theologians conclude, while it is always wrong directly to intend or cause the death of such patients, the natural dying process which would have occurred without these interventions may be permitted to proceed.
While this rationale is convincing to some, it is not theologically conclusive and we are not persuaded by it. In fact, other theologians argue cogently that theological inquiry could lead one to a more carefully limited conclusion.
These moral theologians argue that while particular treatments can be judged useless or burdensome, it is morally questionable and would create a dangerous precedent to imply that any human life is not a positive good or "benefit." They emphasize that while life is not the highest good, it is always and everywhere a basic good of the human person and not merely a means to other goods. They further assert that if the "burden" one is trying to relieve by discontinuing medically assisted nutrition and hydration is the burden of remaining alive in the allegedly undignified condition of PVS, such a decision is unacceptable, because one's intent is only achieved by deliberately ensuring the patient's death from malnutrition or dehydration. Finally, these moralists suggest that PVS is best seen as an extreme form of mental and physical disability -- one whose causes, nature and prognosis are as yet imperfectly understood -- and not as a terminal illness or fatal pathology from which patients should generally be allowed to die. Because the patient's life can often be sustained indefinitely by medically assisted nutrition and hydration that is not unreasonably risky or burdensome for that patient, they say, we are not dealing here with a case where "inevitable death is imminent in spite of the means used."[37] Rather, because the patient will die in a few days if medically assisted nutrition and hydration are discontinued,[38] but can often live a long time if they are provided, the inherent dignity and worth of the human person obligates us to provide this patient with care and support.
Further complicating this debate is a disagreement over what responsible Catholics should do in the absence of a final resolution of this question. Some point to our moral tradition of probabilism, which would allow individuals to follow the appropriate moral analysis that they find persuasive. Others point to the principle that in cases where one might risk unjustly depriving someone of life, we should take the safer course.
In the face of the uncertainties and unresolved medical and theological issues, it is important to defend and preserve important values. On the one hand, there is a concern that patients and families should not be subjected to unnecessary burdens, ineffective treatments and indignities when death is approaching. On the other hand, it is important to ensure that the inherent dignity of human persons, even those who are persistently unconscious, is respected, and that no one is deprived of nutrition and hydration with the intent of bringing on his or her death.
It is not easy to arrive at a single answer to some of the real and personal dilemmas involved in this issue. In study, prayer and compassion we continue to reflect on this issue and hope to discover additional information that will lead to its ultimate resolution.
In the meantime, at a practical level, we are concerned that withdrawal of all life support, including nutrition and hydration, not be viewed as appropriate or automatically indicated for the entire class of PVS patients simply because of a judgment that they are beyond the reach of medical treatment that would restore consciousness. We note the current absence of conclusive scientific data on the causes and implications of different degrees of brain damage, on the PVS patient's ability to experience pain, and on the reliability of prognoses for many such patients.[39] We do know that many of these patients have a good prognosis for long-term survival when given medically assisted nutrition and hydration, and a certain prognosis for death otherwise -- and we know that many in our society view such an early death as a positive good for a patient in this condition. Therefore we are gravely concerned about current attitudes and policy trends in our society that would too easily dismiss patients without apparent mental faculties as non-persons or as undeserving of human care and concern. In this climate, even legitimate moral arguments intended to have a careful and limited application can easily be misinterpreted, broadened and abused by others to erode respect for the lives of some of our society's most helpless members.
In light of these concerns, it is our considered judgment that while legitimate Catholic moral debate continues, decisions about these patients should be guided by a presumption in favor of medically assisted nutrition and hydration. A decision to discontinue such measures should be made in light of a careful assessment of the burdens and benefits of nutrition and hydration for the individual patient and his or her family and community. Such measures must not be withdrawn in order to cause death, but they may be withdrawn if they offer no reasonable hope of sustaining life or pose excessive risks or burdens. We also believe that social and health care policies should be carefully framed so that these patients are not routinely classified as "terminal" or as prime candidates for the discontinuance of even minimal means of life support.
Who should make decisions about medically assisted nutrition and hydration?
"Who decides?" In our society many believe this is the most important or even the only important question regarding this issue; and many understand it in terms of who has legal status to decide. Our Catholic tradition is more concerned with the principles for good moral decisionmaking, which apply to everyone involved in a decision. Some general observations are appropriate here.
A competent patient is the primary decisionmaker about his or her own health care, and is in the best situation to judge how the benefits and burdens of a particular procedure will be experienced. Ideally the patient will act with the advice of loved ones, of health care personnel who have expert knowledge of medical aspects of the case, and of pastoral counselors who can help explore the moral issues and spiritual values involved. A patient may wish to make known his or her general wishes about life support in advance; such expressions cannot have the weight of a fully informed decision made in the actual circumstances of an illness, but can help guide others in the event of a later state of incompetency.[40] Morally even the patient making decisions for himself or herself is bound by norms that prohibit the directly intended causing of death through action or omission, and by the distinction between ordinary and extraordinary means.
When a patient is not competent to make his or her own decisions, a proxy decisionmaker who shares the patient's moral convictions, such as a family member or guardian, may be designated to represent the patient's interests and interpret his or her wishes. Here, too, moral limits remain relevant -- that is, morally the proxy may not deliberately cause a patient's death or refuse what is clearly ordinary means, even if he or she believes the patient would have made such a decision.
Health care personnel should generally follow the reasonable wishes of patient or family, but must also consult their own consciences when participating in these decisions. A physician or nurse told to participate in a course of action that he or she views as clearly immoral has a right and responsibility either to refuse to participate in this course of action or to withdraw from the case, and he or she should be given the opportunity to express the reasons for such refusal in the appropriate forum. Social and legal policies must protect such rights of conscience.
Finally, because these are matters of life and death for human persons, society as a whole has a legitimate interest in responsible decisionmaking.[41]
I feel as if I am drowning in a sea of testoserone. I have lived a life of opportunity and achievement as an American female. I am frightened at seeing very well paid men (who cannot agree) treating a woman as property, extending even to imprisioning her and ordering death. I have not been so afraid since I heard fairy stories of women impsioned in towers when I was a little girl. So, today I renewed my membership in the Republican National Committeee and sent them a check.
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