Since March, 2004, when Pope John Paul II delivered a speech on the use of feeding tubes with patients in a persistent vegetative state, several State Catholic Conferences have revised their advance directive materials. Among them are Colorado, Kansas, Maryland, and Rhode Island. It is interesting to note how each defines ordinary and extraordinary means and how each deals with the issue of artificial nutrition and hydration (ANH). A full review is not possible here. The intent is only to point to what may be an "ethical current." A more complete analysis would be needed to verify whether what seems to be a direction is or is not the case.

The Colorado bishops (August 2007), for example, when discussing ANH, do not distinguish between patients in PVS and other patients. They begin by affirming the strong presumption in favor of providing ANH to all patients and then ask when they may be withheld or withdrawn. The answer: "As long as the person is able to absorb medically assisted food and water they continue to be beneficial in sustaining life. If the person is unable to absorb them, their administration may be discontinued. When inevitable death is imminent, one may cease the administration of food and water if the administration of them provides the person with no comfort and ceasing their administration will not be the cause of death." Earlier in the document, the Colorado bishops defined "ordinary" means as those that "have a medically reasonable hope of sustaining life," and "extraordinary" means as those that "have no medically reasonable hope of sustaining life."

The Rhode Island bishops, in a more recently released advance directive document (February 2008), say this about ANH with regard to all patients: "Food and fluids should always be provided until it is found that the organs can no longer assimilate them, a sign of the onset of natural death. Here, the body's refusal to sustain nourishment is instructive of life's ending, and the removal of nutrition and hydration is an act of allowing nature to take its course rather than of withholding food and drink in order to cause death." They describe ordinary and extraordinary means somewhat differently than the Colorado bishops. Ordinary "care" is said to be "standard, routine treatment that preserves life and health and that promotes comfort and dignity to the patient." Extraordinary "care," on the other hand, is discussed in this way: "Treatments that are not necessary to sustain life but that might offer some benefit to a patient are morally optional and accepted or foregone depending on the circumstances. Here, the benefits are compared to the burdens of a treatment. When the burdens or risks are found to be well out of proportion to the proposed advantages of a treatment, it may be found reasonable to forego it."

In the Kansas Catholic Conference advance directive form itself, released in January 2006, the bishops state this regarding ANH: "I believe that food (nutrition) and fluids (hydration) are not medical treatments, not medical procedures, but ordinary means of preserving life. Therefore, I direct my health care provider (s) to provide me with food and fluids orally, intravenously, by tube, or by other means to the full extent necessary both to preserve my life and to assure me the optimal health possible. Furthermore, if at such time I am unable to eat and drink on my own (i.e. in a natural manner) food and fluids must be provided to me in an assisted manner (i.e. by tubes or a similar manner) unless: (a) my death is imminent (i.e. likely to happen without delay); or (b) I am unable to assimilate food or fluids; or (c) food or fluids endanger my condition." This advance directive form also states that "health care decisions be made which are consistent with my general desire for the use of medical treatment that would preserve my life."

In their advance directive materials (published in 2007), the Maryland bishops define ordinary and extraordinary means as what is "useful" and "useless." "A medical treatment is 'useless' to a particular patient if it cannot bring about the effect for which it is designed. Such an intervention is both ineffective and medically inappropriate." They continue: "A medical means or treatment should not be deemed useless, however, because it fails to achieve some goal beyond what should be expected. For example, a feeding tube is used to provide nutrients to a patient no longer capable of eating; the tube is useful when it delivers these nutrients to the patient who, in turn, absorbs them. It is useless if the patient becomes incapable of absorbing the nutrients the tube delivers. Moreover, a feeding tube should not be described as useless if the nutrients it provides are unable to cure an underlying pathology; the feeding tube should not be expected to restore the patient to consciousness or to remove any other debility not related to the need for nutrients."

They continue: "A seriously ill patient is not necessarily obliged to employ every possible medical means, even those which promise some benefit. In many cases, there is no obligation for patients to accept interventions which impose serious risks, excessive pain, grave inconvenience, prohibitive cost, or some other extreme burden. While the most basic principles of Christian morality oblige us to preserve human life, nonetheless, individuals need not undertake excessively burdensome efforts to preserve their lives. Whether a treatment is necessary or useful to a particular patient is a medical question requiring the expertise of health care professionals. Whether a particular treatment is excessively burdensome to an individual patient is a moral question requiring the advice of a priest or someone else well trained in sound moral theology."

While a more extensive analysis of these (and other) advance directive materials is necessary, they do seem to reflect a different interpretation of the ordinary (proportionate)/extraordinary (disproportionate) means tradition as expressed in Directives 56 and 57, as well as the statement of Pius XII (1956) and the Declaration on Euthanasia (1980). With regard to ANH, the documents do not limit their discussion to patients in a persistent vegetative state, and they seem to say (and require) more than what is said in Directive 58, namely, "a presumption in favor of providing nutrition and hydration to all patients. " Are these different understandings idiosyncratic or do they reflect something else, perhaps an "ethical current."

— RH

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