Editor’s note: This is one in a series of articles that will explain and explore the Church’s teachings on end-of-life and palliative care issues.
Dr. Paul Fiacco is the president and medical director of CNYAIM, a St. Joseph Health clinically integrated network, and is also the medical director of the Trinity Health Integrated Care ACO as well as a full-time family physician at CIVY Family Care in East Syracuse and a parishioner at Holy Cross Church in DeWitt, New York.
The Rev. Charles Vavonese, a retired priest of the Diocese of Syracuse, is the associate chaplain for the Syracuse Region and the author of "I am the Resurrection and the Life," a resource booklet dealing with end-of-life moral issues, which is no longer available. He currently serves patients receiving palliative care as the chaplain for the St. Joseph Health Mobile Integrated Services Team. In addition, Father Vavonese is a weekend assistant at Holy Cross Church in DeWitt.
The previous article applied the principle of double effect developed by St. Thomas Aquinas to pain management, a common end-of-life situation. The Catholic tradition maintains that it is permissible to offer, and even to increase if necessary, a patient's pain medication even if this may have the effect of shortening his or her life, if all of the four criteria for applying the principle are met. For this and all end-of-life decisions, it is best to get the counsel of a priest or other person knowledgeable in Catholic health care ethics.
Nutrition and hydration
The teaching of the Church regarding nutrition and hydration is articulated in the Ethical and Religious Directives (ERD) for Catholic Health Care Services #58, (2018), which states, "In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic and presumably irreversible conditions (e.g., the "persistent vegetative state") who can reasonably be expected to live indefinitely if given such care." This directive means that nutrition and hydration provided by natural or medically assisted means are to be considered basic human care. It is considered ordinary or proportionate care and, in principle, morally obligatory for all patients, including those in a persistent vegetative state.
"In principle" exceptions
There are situations when medically assisted nutrition and hydration may be considered extraordinary or disproportionate care or excessively burdensome, and may be forgone or withdrawn. This may happen when one of the three following conditions are present: imminent death, burdensome treatment, or futile treatment.
When death is imminent
"As a patient draws close to death from an underlying progressive and fatal condition, certain measures to provide nutrition and hydration may become excessively burdensome and therefore not obligatory in light of their very limited ability to prolong life or provide comfort" (ERD, #58, 2018).
The United States Conference of Catholic Bishops points out that, "[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 patients will die if all nutrition and hydration are withheld. But sometimes other causes are at work - the patient may be imminently dying... from an already existing terminal condition" (Hydration and Nutrition: Moral and Pastoral Reflections, USCCB, 1992).
Artificial nutrition and hydration may become "excessively burdensome for the patient or [would] cause significant physical discomfort, for example, resulting from complications in the use of the means employed" (ERD, #58, 2018). Some of these conditions might be determined to be burdensome and therefore morally optional: certain patients become agitated at the sight of the feeding tube and pull it out repeatedly; the feeding tube causes repeated complications, such as infections, bleeding, discomfort, or ulcerations; or the tube obstructs, requiring the constant need for suctioning and recurring pneumonia. In light of these excessive burdens caused by the treatment, it may be forgone or withdrawn.
It is important that the patient or the surrogate determine that artificial nutrition and hydration has become excessively burdensome, not the medical staff.
There are also times when a patient is unable to assimilate or digest the nutrition or hydration, for example during a bowel obstruction or renal or cardiac failure that cannot be treated by proportionate means. In such instances, nutrition or hydration will provide no benefit and may be forgone or withdrawn.
Isn't this murder or suicide?
Catholic moral teaching recognizes that when the burdens of a treatment, including the administration of medically assisted hydration, outweigh its benefits, it is considered to be extraordinary or disproportionate care and may be forgone or withdrawn. St. John Paul II affirmed this teaching, stating "that to forgo or withdraw extraordinary treatments are not suicide or murder" (Evangelium Vitae, 1995).
This article illustrates the Church's teaching that nutrition and hydration provided by natural or medically assisted means are basic human care and are considered ordinary or proportionate care. This is, in principle, morally obligatory even for those in a persistent vegetative state. However, there are situations when medically assisted nutrition and hydration may become extraordinary or disproportionate care, and may be forgone or withdrawn. These situations may occur when death is imminent; when the treatment is determined by the patient or a surrogate to be a burdensome treatment; and, when offering the nutrition and hydration would be futile. St. John Paul II articulated that withdrawing or forgoing such extraordinary or disproportionate care in these cases is not suicide or murder. (This article included information from a communication from National Catholic Bioethics Center staff ethicist Jozef Zalot.)
The next article will discuss the Sacrament of the Sick.