A Dissent From the 'Interim Pastoral Statement on Artificial Nutrition and Hydration'
INTERIM PASTORAL STATEMENT ON ARTIFICIAL NUTRITION AND HYDRATION
Bishop Rene H. Gracida
A Dissent From The "Interim Pastoral Statement On Artificial Nutrition And Hydration" Issued By The Texas Conference Of Catholic Health Facilities And Some Of The Bishops Of Texas
Recently the Texas Catholic Conference in Austin released the final text of the document approved by the Texas Catholic Conference of Health Facilities and sixteen of the twenty-one Bishops of Texas. I had declined to sign the document because I consider it to be seriously flawed.
It seems to me that the document gives a higher priority to efforts to relieve the burden caused by a serious illness rather than efforts to protect the sick person's right to life. The document deals with the withdrawal of nutrition and hydration from a seriously ill patient.
This whole matter is one which is being debated by the legal and medical professions as well as by theologians and ethicists. The Holy See has this whole controversial area of morality under review and will undoubtedly issue a major declaration on the subject sometime in the next year or two.
In the meantime, I would have preferred to see my fellow Bishops of Texas issue a document which would have made a stronger statement in support of the sick person's right to receive food and drink as the basic necessities of life.
My specific objections to the text of the statement which was recently made public, are:
1. In the title and throughout the text, the phrase "artificial nutrition and hydration" is used. This is inaccurate: the food and water used are not artificial. It is medically appropriate to speak of "artificially assisted nutrition and hydration." It is the mode of assistance that is artificial.
2. Under "Basic Moral Principles" the Declaration on Euthanasia is used selectively. As the title of that document indicates, one must begin with a rejection of euthanasia—defined by the Declaration as "an action or an order that all suffering may in this way be eliminated."
Only "after" one has established that an omission of care or treatment is not directly intended to bring about death should one turn to the complex task of assessing benefits and burdens. The question of intention is central here: If the removal of a life-sustaining procedure is intended to avoid an unreasonable burden of the procedure, so that a quicker death is only an unintended side-effect of the decision, it is not a case of euthanasia.
3. Also not treated here is the question whether artificially assisted feeding may be classified as "normal care" rather than "treatment." The "Declaration" says normal care must be provided even when one has removed "forms of treatment that would only secure a precarious and burdensome prolongation of life" for an imminently dying patient.
Whether tube feeding may constitute "normal care" is not currently resolved by the magisterium; three non-magisterial bodies (Pontifical Council Cor Unum, editorial board of La Civilta Cattolica, and a working group of the Pontifical Academy of Sciences) have issued statements answering the question in the affirmative. If tube feeding has some aspects of "normal care," this would strengthen the presumption in favor of providing it in most cases.
4. The inclusion of burdens on "others—family, care provider, or community"—is more broadly stated than in existing Church documents. The Declaration on Euthanasia speaks of the "patient himself" validly making a self-sacrificing decision not to burden other: when those "others" are the agents making the decision, other factors (including the Golden Rule) come into play.
"All" long-term care for seriously impaired patients is a "burden" on the community, but it may be a burden that has to be willingly shouldered: "The respect, the dedication, the time and means required for the care of handicapped persons, even of those whose mental faculties are gravely affected, is the price that a society should generously pay in order to remain truly human" (Document of the Holy See for the International Year of Disabled Persons, 1981.)
5. The phrase about "investment in medical technology and personnel disproportionate to the expected results" is taken from a paragraph in the Declaration on Euthanasia that concerns "the most advanced medical techniques," especially those "at the experimental stage." This document applies the phrases to life-supporting means generally.
6. I know of no Church document that says treatment is disproportionate when it involves "inequitable resource allocation." This could be a broad loophole for communities saying that severely impaired persons are not worth the money. The phrase should be clarified or deleted.
7. The restrictive statement that "maintenance of life" is a benefit only when it involves reasonable hop of recovery" could ground discriminatory withholding of life preserving means from people with incurable disabilities.
It vitiates the principle that everyone has the same basic "right to life" regardless of age or condition, which in Catholic social teaching means that every person has the same basic right to the necessities that sustain life. Life is "always a good." How can it be a good without being a benefit?
8. The equation between "foregoing" and "withdrawing" is an oversimplification. What of cases where initiation of tube feeding entails the transient risks and burdens of minor surgery under general or local anesthesia, but its maintenance does not involve these burdens? Must this change in the burden/benefit calculus be ignored?
9. The claim that the NCCB Pro-Life Committee came to the "same conclusion" is overstated. The Committee's chief message was rejection of any efforts at "intentionally hastening the deaths of vulnerable patients by starvation or dehydration"; as was said in point #2 above, the text under consideration does not have this focus.
Also, the Pro-Life Committee document clearly supports tube feeding that can "effectively preserve 'life' without involving too grave a burden"; the present draft, as noted above, judges effectiveness in terms of preserving "life with reasonable hope of recovery," which is a different standard.
10. The question of "cause of death" is a major open question in the current debate. This text overstates the importance of that question, because traditional moral teaching puts great weight on "intention."
It also understates the causal role of an omission of nutrition and hydration in hastening death, in cases where a patient could have survived in a medically stable condition for years with continued feeding. The phrase "proximate physical means" is obscure, and should have been replaced by "proximate physical cause of death." One can recognize that the omission is the proximate cause leading to death, while reaffirming that the hastening of death is "praeter intentionem" in some cases.
11. The claim that all these decisions are made "by the patients themselves and by no one else" is not supported in the Church documents. The Declaration says "account will have to be taken of the 'reasonable' wishes of the wishes of the patient 'and the patient's family,' as also of 'the advice of the doctors' who are specially competent in the matter."
In cases of doubt "it pertains to the conscience either of the sick person, 'or' of the doctors, to decide, in the light of moral obligations and of the various aspects of the case." In the Declaration a major "moral obligation" binding on "all" decision makers is the rejection of euthanasia by action or omission. Theses qualifications are all absent from (even explicitly rejected by) the document.
12. To say the "morally appropriate" withdrawal of tubal feeding is not "abandoning the person" is a truism. It is equally true to say: "The morally inappropriate withdrawal of tube feeding 'is' abandonment of the person."
This leaves us nowhere, because the text gives no guidelines on when the burdens of artificially assisted feeding are grave enough to render this means optional (except for the overboard standard cited above that whatever the patient says is right).
13. The statement that the patient should not be impeded from "taking the final step" has an ominous sound to it; it might give the impression that hastening death can be directly intended. A phrase like "accepting the inevitability of death " would have been better.
14. The phrase "threat 'of' life" on page 5, line 19 is, I hope, a misprint for "threat 'to' life." The presumption seems to be that death from a life-threatening condition is the "normal consequence" that should occur, and one needs a special reason to "impede" this "normal" state of affairs.
The burden of proof should go the other way: We have a "prima facie" obligation to save someone's life unless there is a special reason (e.g., ineffectiveness, grave burdensomeness) not to do so. One senses here a very passive model for human action in the world in cases of preventable death—one that does not comport well with the stated "presumption" in favor of averting death.
15. The document as a whole should have distinguished more clearly between two classes of patients: Those who are dying soon no matter what we do for them (e.g., terminal cancer patient), and those who are medically stable and are "not" dying if provided with continued nutrients and fluids.
A much more permissive standard is possible for the former class of patients, for whom continued feeding may become strictly useless in prolonging life. A strong presumption could be established in favor of life-sustaining feeding for the latter class, rebuttable in cases of excessive burden.
A strong presumption here is especially important because, in some celebrated cases, tube feeding has apparently been withdrawn from the latter class of patients precisely because they are "not" dying and someone wants death to occur (see ACLU brief in the Hector Rodas case, cautionary statements by ethicist Daniel Callahan, and concurring opinion by Judge Lynn Compton in the Elizabeth Bouvia case).
This statement was published in the May 25, 1990 edition of the "Diocesan Press."
