Catholic Health World

Bishops clarify ethical directive on artificial nutrition, hydration

By PAMELA SCHAEFFER

BALTIMORE — The United States Conference of Catholic Bishops voted overwhelmingly on Nov. 17 to approve new wording for Directive 58 in the Ethical and Religious Directives for Catholic Health Care Services. The revised directive cites an obligation to provide patients with food and water, including medically assisted nutrition and hydration for patients who cannot take food by mouth.

The new wording was proposed by the bishops' Committee on Doctrine, headed by Bishop William Lori of Bridgeport, Conn., following consultation with ethical and medical experts, including CHA leaders.

The obligation cited in the revised directive generally extends to patients in a persistent vegetative state. Artificial nutrition and hydration becomes "morally optional" when a patient is close to death and the procedure is unlikely to prolong life and may become "excessively burdensome." (See below to compare the wording of revised Directive 58 with the language it replaces.)

The new directive is 144 words long, compared to just 40 words in the more softly worded current directive. Presently, Directive 58 describes "a presumption in favor of providing" — rather than an obligation to provide — food and water to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens on the patient.

Fr. Thomas G. Weinandy, OFM Cap, executive director of the doctrinal committee, said the revision had been proposed to reflect the teaching of Pope John Paul II in a 2004 address to a conference in Rome on patients diagnosed as in a "vegetative state." There, the pope said these patients were entitled to ordinary care, including food and water, even if artificially administered. In 2007, the Vatican's Congregation for the Doctrine of the Faith, responding to a request from U.S. Catholic bishops for clarification, described the administration of food and water "even by artificial means" as "in principle an ordinary and proportionate means of preserving life."

Sr. Carol Keehan, DC, CHA president and chief executive officer, participated in discussions on the revised text and attended part of the three-day USCCB meeting here, Nov. 16-19. She said following the vote, "CHA is pleased that the bishops' conference has further clarified the question of nutrition and hydration and distinguished between patients who are dying and those who are in a persistent vegetative state. CHA is pleased to have contributed to the dialogue with clinicians, ethicists and mission and pastoral care people. This process allowed those who care for these patients daily to contribute their insights and expertise. The revised directive will help enhance the care and sensitivity to these patients and their families."

The revised directive gained support well beyond the required simple majority it needed to pass, with 98 percent of the bishops giving it a thumbs up, following a brief debate over a proposed amendment to substitute "permanent vegetative state" for "persistent vegetative state." The amendment failed after Bishop Lori noted that the word "persistent" is widely used by physicians and ethicists in the U.S. and more accurately reflects the intent, if not the precise wording, of Pope John Paul II, who, in his 2004 statement, used the term "permanent" vegetative state but allowed for the possibility that such patients might recover.

Both Bishop Lori and Cardinal Justin Rigali, who heads the bishops' Committee on Pro-Life Activities, said in response to questions from a reporter, that they are pleased with the directive's final wording, which has been successively refined during the consultations. "Yes, I am happy with it," Cardinal Rigali said. "I am very supportive of the doctrine committee." Bishop Lori said in an interview with Catholic Health World, "It was a consultative process, and I am delighted we could arrive at a text that would seem to be helpful to all concerned."

Consultants besides CHA, according to Lori, included the bishops' pro-life committee, the Catholic Medical Association, the National Catholic Partnership on Disability and the National Catholic Bioethics Center, and the USCCB Task Force on Health Care.

Asked whether the revised text might suggest the doctrinal committee was backing away from Catholic tradition in moral theology, which weighs the benefits and burdens of medical interventions in determining whether they are morally obligatory, Bishop Lori said the new text is "not intended to discredit the burden-benefit analysis" but rather is intended to ensure "that the language employed would guide teachers of the faith and (health care) practitioners and ordinary Catholics in making an appropriate analysis of when artificial nutrition and hydration becomes burdensome." The current text of Directive 58 is more direct in inviting a burden-benefit analysis.

Fr. Weinandy said the fifth edition of the Ethical and Religious Directives will be printed soon, probably by early 2010. An electronic version is available at chausa.org/erdrevise. The only change, he said, regards Directive 58.

In other actions, the bishops approved a document on marriage titled "Marriage: Love and Life in the Divine Plan," and a document called "Life-giving Love in an Age of Technology," expressing compassion for couples experiencing infertility but reaffirming church teaching against reproductive technologies such as in vitro fertilization that divide "the unitive and procreative aspects of sexuality."

The bishops expressed unanimous support for a statement by conference president Cardinal Francis George, OMI, thanking members of the U.S. House of Representatives for their "principled step" to ensure that no federal money will go to fund abortions in the health reform bill moving through Congress. "We remain deeply concerned about the debate that now moves to the Senate, especially as it will affect the poor and vulnerable and those at the beginning and end of life," Cardinal George said.

Directive 58 on artificial nutrition, hydration

Revised Directive 58 as it appears in the fifth edition of the Ethical and Religious Directives for Catholic Health Care Services:

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. Medically assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be "excessively burdensome for the patient or (would) cause significant physical discomfort, for example resulting from complications in the use of the means employed." For instance, as a patient draws close to inevitable 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.

Directive 58 as it appears in the current fourth edition of the Ethical and Religious Directives:

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.

Copyright © 2009 by the Catholic Health Association of the United States
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