Catholic Stance on Nutrition & Hydration

Catholic Stance on Nutrition & Hydration

Goal • Understand the Catholic tradition regarding withholding/removing nutrition and hydration • Recognize the special ethical problems for PVS patients • Appreciate the state restrictions on removing ANH • Comprehend the challenges of the Papal Allocution • Consider practical ways to clarify confusion about ANH and PVS

GOAL • Review Cases: • 73 year old esophageal cancer • Mrs. Vanderbilt • Nancy Cruzan • Terri Schiavo

Encyclicals Papal Statements Congregations (CDF) Cong Doctrine of Faith Pontifical Council for Life -Gospel of Life JPII -Pius XII -PJII Allocution 3/25/04 -Declaration on Euthanasia 1980 -”Vatican Statement” Church Teaching:Placing them in Context

Bishops Conference USCCB FL Bishops Conference Individual Bishops -Ethical and Religious Directives for Healthcare (ERD) 2001 -Schiavo Statements Church Teaching:Placing them in Context

Vary in “teaching authority” • Frequency and impetus for speaking • Speaking at 10,000’ General principles • Some principles highly refined and admit of no exceptions (e.g., no directly intending to take innocent life) • Directly intending? • Innocent life?

History • 16th Century Dominican – Francisco DeVitoria addresses the question: • “…would a sick person who does not eat because of some disgust for food be guilty of a sin equivalent to suicide?...” • And answers, “…If the patient is so depressed or has lost his appetite so that it is only with the greatest effort that he can eat food, this right away ought to be reckoned as creating a kind of impossibility, and the patient is excused, at least from mortal sin, especially if there is little or no hope of life.”

History • DeVitoria: • “Chickens and partridges, even if ordered by the doctor, need not be chosen over eggs and other common items, even if the individual knew for certain that he could live another 20 years by eating such special foods.”

History Puis XII “The Prolongation of Life” 1958 • “Normally one is held to use only ordinary means—according to the circumstances, places, times, culture—that is to say means that do not involve and grave burden for one self or others. A more strict obligations would be too burdensome for most people and would render the attainment of a higher more important good too difficult. Life, health and all temporal activities are subordinated to spiritual ends.” Appropriate v. inappropriate Extraordinary v. ordinary

History Declaration on Euthanasia CDF 1980 • “…people prefer to speak of proportionate and disproportionate”…it will be possible to make a correct judgment by studying the type of treatment, its degree of complexity of risk, costs and possibility of using it, and comparing these to the results to be expected taking into account the state of the sick person, and his or her physical and moral resources…when inevitable death is imminent in spite of the treatments used, it is permitted in conscience to make the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due a sick person in similar cases is not interrupted…”

Disproportionate • Excessively burdensome • Too painful • Too damaging to the patient’s self & functioning • Too psychologically repugnant to the patient • Too suppressive of mental life • Prohibitive cost • Burdensome to whom? • Patient • Family • Community

ERDs • “The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life-sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching.”

ERDs Directive 56 • “A person has a moral obligation to use ordinary or proportionate means of preserving his or her life. Proportionate means are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community.”

ERDs Directive 57 • “A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patient's judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.”

ERDs 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.”

ERDs Directive 60 • “Euthanasia is an action or omission that of itself or by intention causes death in order to alleviate suffering. Catholic health care institutions may never condone or participate in euthanasia or assisted suicide in any way.” Appropriate v. inappropriate Letting die v. euthanasia Secondary intent v. direct intent to cause death

Papal Allocution 3/25/05 • I should like particularly to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. • “Its use (i.e., nutrition and hydration), furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering.

Papal Allocution • First use of natural means / medical act • In principle, not every case. When? • Does not nourish • Does not alleviate • Patient finds it excessively burdensome • Quality of life language is indeed ambiguous.

Papal Allocution • All persons, no matter how debilitated or cognitively incapacitated, have dignity. A man, even if seriously ill or disabled in the exercise of his highest functions, is and always will be a man, and he will never become a "vegetable" or an "animal". • Referring to PVS patients • Not immediately applicable to all patients

Papal Allocution • In this regard, I recall what I wrote in the Encyclical Evangelium Vitae, making it clear that "by euthanasia in the true and proper sense must be understood an action or omission which by its very nature and intention brings about death, with the purpose of eliminating all pain"; such an act is always "a serious violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person" (n. 65).

Papal Allocution Applied to cases • 73-year-old with esophagus CA • Mrs Vanderbilt • Schiavo

Florida Bishops 3/28/05 We are called to provide basic means of sustenance such as food and water unless they are doing more harm than good to the patient, or are useless because the patient’s death is imminent. As long as they effectively provide nourishment and help provide comfort, we should see them as part of what we owe to all who are helpless and in our care. In certain situations a patient may morally refuse medical treatment and such decisions may properly be seen as an expression of our hope of union with God in the life to come. We pray that Terri Schindler Schiavo's family and friends, and all who hold power over her fate, will see that she continues to receive nourishment, comfort and loving care.

Summary • Unfolding of doctrine • Not fully unfolded • No categorical prohibition • Always a presumption • Clearest: • Capacitated patients • Patients with clear directives • Patients with little burden/ large benefit/ primary intent is death

Summary • Ethics management • Avoid a rush to judgment • People know where to turn • Greatest concerns with PVS & H20 • Communications: “Catholic institutions follow the wishes of patients insofar as they are consistent with tradition” • Very few ask for treatments that cannot be honored

Catholic Stance on Nutrition & Hydration