BY: MICHAEL R. PANICOLA, PhD
Dr. Panicola is the ethicist for SSM Health Care, St. Louis. An
expansion of this article appears in The Hastings Center Report, November-December,
2001, vol. 31, no. 6.
The Catholic Tradition Offers Guidance for the Treatment of Patients in
a Persistent Vegetative State
The issue of withdrawing medically assisted nutrition and hydration from
patients in a persistent vegetative state (PVS) continues to be a source of
conflict for Catholics. This was illustrated recently in the cases involving
Hugh Finn and Steven Becker, in which Catholics of presumed goodwill came
down on both sides of the fence.1 On one side were those who argued
that withdrawing medically assisted nutrition and hydration from Finn and
Becker was morally acceptable in light of a holistic benefit-burden analysis.
On the other side were those who argued that withdrawing medically assisted
nutrition and hydration from Finn and Becker was equivalent to murder in that
both men were essentially starved to death when they could otherwise have
lived for several years.
One reason for the conflict among Catholics is that the medical reality
of PVS is often misunderstood. PVS is an eyes-open state of unconsciousness
with sleep-wake cycles in which the patients are completely unaware of themselves
and their surroundings.2 PVS may be caused by a traumatic brain
injury or by a nontraumatic brain injury that results in the loss of all higher
brain functions with either complete or partial preservation of brainstem
autonomic functions. Recovery of consciousness is highly improbable after
twelve months for patients in a PVS caused by a traumatic brain injury and
after three months for patients in a PVS caused by a nontraumatic brain injury.3
The life expectancy of patients in a PVS is greatly reduced, with the average
ranging from two to five years. Death is usually brought on by an infection
in the lungs or urinary tract, respiratory failure, or sudden death of unknown
cause.4 The length of survival depends in part on how aggressively
such medical complications are treated.
Another reason for the conflict among Catholics is that the moral issue
of prolonging the lives of patients in a PVS with medically assisted nutrition
and hydration has not been resolved by the magisterium and thus is open for
discussion in the Catholic community.5 Yet, even though this issue
has not been settled at the hierarchical level and serious disagreement exists
among Catholics, three particular principles in traditional Catholic teaching
on prolonging life suggest that withdrawing medically assisted nutrition and
hydration from patients who have been accurately diagnosed in a PVS is morally
justified and is most in keeping with the teaching itself.
Human Life Is a Basic But Limited Good
Traditional Catholic teaching on prolonging life affirms that human life
is a basic and precious good that flows forth from God. The love that God
has for humanity is shown most enduringly in the life of the human person
who has been made in God's image. "Life as a sign of God's love and care is
sacred, has meaning because of God's love and not because of personal merit,
and should be treated with dignity and respect at every stage."6
The good of human life is tied, not to functional ability or social utility,
but to the very fact that it comes from God.
It is because human life is an utterly free and unmerited gift from God
that one has a duty to prolong life. Fulfilling this duty in the course of
one's existence may sometimes involve either seeking or receiving medical
care. However, Catholic teaching on prolonging life has always held that the
duty to maintain life through medical means is limited. It ceases when medical
treatment cannot offer one a reasonable hope of benefit in terms of pursuing
the spiritual goods of life (love of God and love of neighbor), or can
only offer one a physical condition in which the pursuit of the spiritual
goods of life will be profoundly frustrated in the mere effort for survival.7
This is exactly what Pius XII means when he states:
But normally one is held to use only ordinary means — according to circumstances
of persons, places, times and culture — that is to say, means that do not
involve any grave burden for oneself or another. A more strict obligation
would be too burdensome for most men and would render the attainment of
the higher, more important good too difficult. Life, health, all temporal
activities are in fact subordinated to spiritual ends.8
The pursuit of the spiritual goods of life is intimately connected with
human life in that physical existence affords one the opportunity to love
God through loving others.9 One is able to love God in the context
of human life through loving others as oneself. Yet human life is not itself
an absolute good. The good of life is a limited good precisely because it
is the basis for pursuing the higher, more important spiritual goods of life
(love of God and love of neighbor).
Applying this understanding of human life to patients in a PVS suggests
that the duty to prolong their lives has ceased. Because these patients have
reached a point where their ability to pursue the spiritual goods of life
has been totally eclipsed, the best treatment is no treatment. They
are beyond the reach of medical treatment (including medically assisted nutrition
and hydration) and should be provided only supportive nursing care so that
they may be allowed to die in relative peace, without having their physical
lives prolonged by unreasonable medical means.
To be clear, though, the decision to allow patients in a PVS to die does
not imply that their lives are less valuable than others. In truth, "every
human being, regardless of age or condition, is of incalculable worth."10
Rather, the decision is based on the fact that physiological existence no
longer offers these patients any hope at all of pursuing those goods for which
human life is the fundamental condition.
This understanding of human life as a limited good subordinated to the spiritual
goods of life has not been embraced by everyone. Some authors argue that certain
goods cannot be weighed one against the other; such goods are "incommensurable"
because they are necessary for integral human fulfillment.11 Aesthetic
experience, human life, knowledge, play, practical reasonableness, religion,
and sociability are all examples of incommensurable goods.12 These
goods should be recognized and respected in the context of human life. However,
it is not always possible to promote all of these goods in a particular situation;
thus a reasonable selection of one or another good to be more fully realized
is morally acceptable. Still, no reasonable grounds suffice for sacrificing
one good for another. It is never right under any circumstance whatsoever
to attack one of these goods. Incommensurable goods must all be accepted as
moral realities and appreciated in every situation.
This concept of goods is problematic for two reasons. First, it fails to
recognize that goods must often be weighed one against the other. Because
of the limits of temporal existence, a choice of one good automatically rules
out a choice of others. By choosing to spend the morning playing a round of
golf, for example, one closes the door on other possible options, at least
while engaged in the activity of golfing. During the round of golf, one is
unable to pursue such other goods of life as furthering one's knowledge of
the arts or strengthening one's faith commitment through attending a liturgy.
Though not attacking these other goods, one is making a value choice for one
good over the others. This is a weighing of goods and suggests that goods
are not incommensurable in reality.
Second, this concept of goods tends toward vitalism. If the good of human
life cannot be weighed against other goods, then life has to be prolonged
insofar as doing so is a physical possibility. One can never attack the good
of life by subordinating it to other goods. Does this, however, seem prudent?
Are there no limits to life? Do we exist simply so that our vital physiological
functions can be maintained? Or do we exist so that we can experience life,
engage loved ones, interact with others, participate in society, pursue personal
interests, at least at a minimal level? It would be devastating to accept
human life as an incommensurable good that cannot be compared to other goods
in reaching medical-moral decisions. Doing so would negate the rights of patients
to make autonomous decisions on limiting medical care; would lead to overtreatment,
whereby some lives would be prolonged far beyond what is reasonable; and would
impose a major burden on families to meet the demands and absorb the costs
associated with caring for patients whose lives are prolonged unnecessarily.
Human life is indeed always a good, as some of the supporters of the incommensurable
goods theory point out, but it is a good that need not and should not be made
Treatment Must Offer a Reasonable Hope of Benefit
Traditional Catholic teaching on prolonging life asserts that for a medical
means to be considered morally obligatory it must offer one a reasonable hope
of benefit. Yet how does one determine whether a medical means is beneficial?
In assessing the potential benefit of medical treatment, one must consider
several criteria. As the Congregation for the Doctrine of the Faith notes
in its "Declaration on Euthanasia," one can determine whether a medical means
is proportionate or beneficial by "studying the type of treatment to be used,
its degree of complexity or risk, its cost and the possibilities of using
it, and comparing these elements with the result that can be expected, taking
into account the state of the sick person and his or her physical and moral
resources."13 All of these criteria coalesce in determining whether
a particular medical means offers one a reasonable hope of benefit.
Although it is clear that a medical treatment must be beneficial to be considered
morally obligatory, it is less clear what constitutes a "benefit." In the
medical context, a treatment is considered beneficial if it restores one's
health, relieves one's pain, improves one's physical mobility, returns one
to consciousness, enables one to communicate with others, and so on. Catholic
teaching on prolonging life recognizes all of these improvements in one's
condition as benefits; but it specifies that, to be truly beneficial,
treatment must improve one's condition to the point that one is able to pursue
the spiritual goods of life, at least at a minimal level, without experiencing
significant burdens.14 Bishop William H. Bullock, DD, EDS, of the
Diocese of Madison, WI, describes this well:
God has given life to carry out human activities that make us better persons,
serve the community and lead to eternal life with Him. Therefore, the benefit
of care or treatment to prolong life of a dying person, or of a person for
whom these human activities have become very difficult or even no longer
possible, diminishes in proportion to what remains possible for them.15
This more holistic understanding of benefit, expressed in Catholic teaching
on prolonging life and summarized eloquently by Bishop Bullock, is profoundly
connected to the Catholic view of the human person as a physical, psychological,
social, and spiritual being whose ultimate goal in life is to love God through
loving others as oneself.
Applying this understanding of benefit to patients in a PVS suggests that
medical treatment is not morally obligatory because it provides no reasonable
hope of benefit to such patients. Although medically assisted nutrition and
hydration provide the sustenance necessary to prolong the lives of patients
in a PVS, it is not considered a beneficial medical treatment in the
Catholic moral tradition because it does not restore such patients to a relative
state of health. No matter how long medically assisted nutrition and hydration
prolongs the lives of patients in a PVS, it will never improve their overall
medical condition to the point where they can again pursue the spiritual goods
of life. The tragic reality is that these patients are no longer capable of
receiving any meaningful benefit from medicine's efforts to keep them alive.
Not everyone has embraced this understanding of benefit. Some authors contend
that the mere fact that human life can be prolonged is itself a benefit sufficient
to justify continued medical treatment. William E. May, in an article he wrote
with several colleagues, argues that feeding and hydrating patients in a PVS
"by means of tubes is not useless in the strict sense because it does
bring to these patients a great benefit, namely, the preservation of their
lives and the prevention of their death through malnutrition and dehydration."16
May and his coauthors do not say as much, but it is clear that his concept
of benefit presupposes that human life is a good that cannot be weighed against
other goods. The criticisms concerning the incommensurable goods theory relate
to the argument of May, et al., as well.
Still, the question remains: Why is the mere prolongation of life itself
a "great benefit"? How do patients who cannot experience life, engage loved
ones, interact with others, participate in society, pursue personal interests,
at least at a minimal level, benefit from having their lives prolonged? These
are questions that May and his coauthors are unable to answer because they
fail to recognize that "what is truly beneficial to us as human persons is
a broad human judgment" encompassing more than life's physiological dimension.17
Traditional Catholic teaching on prolonging life has never accepted so narrow
a concept of benefit as the one proposed by May and his colleagues. To do
so would be an idolization of human life and an abandonment of the fundamental
Christian conviction that human life is not the final end of the person. The
late Rev. Richard A. McCormick, SJ, STD, once sketched a "fanciful scenario"
speaking to this point: "Imagine a 300-bed Catholic hospital with all beds
supporting PVS patients maintained for months, even years by gastrostomy tubes.
. . . An observer of the scenario would eventually be led to ask: 'Is it true
that those who operate this facility actually believe in eternal life?'"18
Some authors, attempting to circumvent the argument that the mere prolongation
of life is not a meaningful benefit, maintain that medically assisted nutrition
and hydration is a basic element of care, rather than medical treatment, and
as such should always be provided to a patient. Robert Barry argues that medically
assisted nutrition and hydration is not on the same moral plane as medical
treatment because, whereas medical treatment aims at curing a clinically diagnosable
condition, medically assisted nutrition and hydration meets "the basic needs
of organisms to function and grow, and they are not remedies of diseases in
and of themselves."19 But this argument is seriously flawed because
it misrepresents the nature of the therapy. No significant moral difference
exists between medically assisted nutrition and hydration and other medical
interventions such as mechanical ventilation, which most experts agree is
a medical treatment. Both are administered and supervised by medical professionals,
and both are geared toward restoring a vital physiological function. As Albert
The situation is similar to a patient who cannot breathe unaided because
some part of the respiratory system is not functioning properly. Oxygen, water,
and food are all necessary elements for maintaining life. If because of some
current pathology, the person requires that these be supplied by technological
means, then it would seem that the same moral principles can be applied to
determine the respective moral obligations to initiate or continue life conserving
procedures. By technological means we are circumventing an obstacle that prevents
food and water (or oxygen) from entering the body in the normal manner. Hence
when we cease by-passing the obstacle, the person dies from a combination
of his pathology and the lack of nutrition and hydration (or oxygen).20
Even if it were determined that medically assisted nutrition and hydration
is a basic form of care, decisions to initiate or continue it would still
hinge on the moral norms articulated in traditional Catholic teaching on prolonging
life.21 Even the great 16th- and 17th-century moral theologians
held that the taking of food could be considered extraordinary or morally
optional, given one's condition and circumstances. These theologians were
talking about food in its natural state. How much more would their comments
apply to the use of medically assisted nutrition and hydration supplied either
through creating a surgical opening in the gastrointestinal tract or through
an intravenous line?
Treatment Must Not Impose An Excessive Burden
Traditional Catholic teaching on prolonging life holds that for a medical
means to be considered morally obligatory it must, first, offer a reasonable
hope of benefit, and, second, impose neither an excessive burden on the patient
nor an excessive expense on the patient's family or community.22 Given
the fact that medically assisted nutrition and hydration provides no reasonable
hope of benefit to patients in a PVS, and thus is not medically required,
it might seem that a discussion of burdens is unnecessary. This may be true
on some level. Nevertheless, burden factors are given considerable weight
in Catholic teaching on prolonging life; it is therefore important to see
how they come into play in cases involving patients in a PVS.
The excessive-burden principle is frequently set aside in discussions concerning
the prolongation of life for patients in a PVS. Most commentators assume that
such patients cannot experience pain and suffering because of the profound
devastation to their brains.23 This conclusion is apparently accurate
in the light of positron-emission tomography studies that show, in the cortical
and subcortical areas of the cerebral hemispheres of PVS patients, severely
depressed energy metabolism levels comparable to that found in "brain-healthy"
patients under general anesthesia.24 Still, just as a falling tree
makes a noise even if no one hears it, burdens remain even for patients who
do not, in the proper sense, experience them. Patients in a PVS are susceptible
to a host of problems that qualify as burdens — feeding-tube site infections,
incontinence and other bowel and bladder disorders, bedsores, and deformities
caused by muscle deterioration and contracture, among others.
What is more, the element of burden can be particularly real for the families
of patients in a PVS. Providing medical care to such patients can be costly,
especially if their lives are prolonged for many years, and take a heavy toll
physically, emotionally, and spiritually on family caregivers. Anyone familiar
with the stories of Karen Ann Quinlan and Nancy Cruzan can attest to this
point. But the broader burdens that accumulate for such families are, for
various reasons, either overlooked or denied by those who insist that withdrawing
medically assisted nutrition and hydration from PVS patients is morally wrong;
these writers seem to think such burdens are unimportant.25 This
is not the traditional viewpoint, however. In Catholic teaching on prolonging
life, burdens have always been understood broadly, to include not just those
borne by the patient but also those borne by the family and the community
at large. This broader notion of burden has its roots in a theological anthropology
that views the person as a social being with deep familial and communal ties.
Burdens that affect others are, in this view, morally relevant considerations
in decisions about prolonging life.
Ideally, a patient should be able to evaluate the benefits and burdens of
treatment, especially those likely to affect others. But this is not always
possible. When patients are no longer able to make decisions for themselves,
because their ability to do so is diminished or absent, someone else must
make them; whoever assumes the role of surrogate should base such decisions
primarily on the patients' best interests, even when the consequences strongly
affect others, family and/or community, for example. However, these other
people should not be excluded from the assessment altogether. We should, while
being mindful of our commitments to the most vulnerable among us, consider
the burdens that families and communities endure in caring for PVS patients,
all the while guarding against "utilitarian perspectives so deeply sunk into
the consciousness of the contemporary world."26 This is a harrowing
choice, to be sure, but one that we must nevertheless undertake as social
beings confronted by medicine's virtually unlimited power to prolong life.
Are burdens ever decisive in PVS cases? The truth is, probably not. Still,
burdens are objectively discernible, morally significant factors that merge
with other factors, thus reinforcing the argument that life-prolonging measures,
including medically assisted nutrition and hydration, are not obligatory for
persons in a PVS.
Respecting Life's Limits
It is understandable that Catholics are concerned about how patients are
treated as they approach the mystery of death, especially in a time when euthanasia
and physician-assisted suicide are gaining popular support. However, this
concern is misplaced when it comes to decisions to withdraw medically assisted
nutrition and hydration from patients who have been accurately diagnosed as
being in a PVS.
Such concern is misplaced because these decisions are morally justified
according to traditional Catholic teaching on prolonging life and indeed seem
most consonant with the basic principles of the teaching itself. Decisions
to withdraw nutrition and hydration in such cases will, without question,
be emotionally difficult for both family members and the medical professionals
involved. Nevertheless, moral issues should not be reduced to emotional responses.27
One may feel that one is killing the patient by withdrawing medically
assisted nutrition and hydration, but the ultimate cause of death is the underlying
pathology that made the nutrition and hydration necessary in the first place.
In cases of PVS, a decision to withdraw medically assisted nutrition and
hydration is not the moral equivalent of murder but an acceptance of the limits
of life, a faith-filled affirmation "that the person has come to the end of
his or her pilgrimage and should not be impeded from taking the final step."28
As Catholics, we are often quick to witness to the value of life, but we should
be equally quick to witness to the limits of life. A recognition of life's
limits would be as clear a statement as any that we believe and trust in God
who has been most fully revealed in the life, death, and resurrection of Jesus
- See Russell Smith and Michael Valente, Medical Dilemmas and Moral
Decision Making, Diocese of Richmond, Richmond, VA, 2001.
- Multi-Society Task Force on PVS, "Medical Aspects of the Persistent Vegetative
State," New England Journal of Medicine, May 6, 1994, pp. 1,499-1,508,
and June 2, 1994, pp. 1,572-1,579.
- Charles Weijer, "Cardiopulmonary Resuscitation for Patients in a Persistent
Vegetative State: Futile or Acceptable?" Canadian Medical Association
Journal, February 24, 1998, pp. 491-493; Multi-Society Task Force on
- Robin S. Howard and David H. Miller, "The Persistent Vegetative State,"
British Medical Journal, February 11, 1995, pp. 341-342.
- United States Conference of Catholic Bishops, Ethical and Religious
Directives for Catholic Health Care Services, Revised, July 2001, Washington,
DC, p. 30.
- Dennis Brodeur, "Feeding Policy Protects Patients," Health Progress,
June 1985, p. 39.
- James J. Walter, "The Meaning and Validity of Quality of Life Judgments
in Contemporary Roman Catholic Medical Ethics," in Quality of Life: The
New Medical Dilemma, James J. Walter and Thomas A. Shannon, eds., Paulist
Press, New York City, 1990, pp. 78-88.
- Pius XII, "The Prolongation of Life," in Critical Choices and Critical
Care, Kevin W. Wildes, ed., Kluwer Academic Press, The Netherlands,
1995, p. 192.
- Richard A. McCormick, "To Save or Let Die: The Dilemma of Modern Medicine,"
JAMA, July 8, 1974, pp. 172-176.
- McCormick, p. 176.
- See, for example, Germain Grisez, Contraception and the Natural Law,
Bruce, Milwaukee, 1964; Germain Grisez, The Way of the Lord Jesus, Franciscan
Herald Press, Chicago, 1983; and John Finnis, Fundamentals of Ethics,
Georgetown University Press, Washington, DC, 1983, and Natural Law and
Natural Rights, Clarendon Press, Oxford, England, 1984.
- This list of "incommensurable" goods is found in Finnis, Fundamentals
of Ethics, p. 51, and Natural Law and Natural Rights, pp. 85-90.
- Congregation for the Doctrine of the Faith, "Declaration on Euthanasia,"
in Walter and Shannon, eds., Quality of Life, p. 263.
- Walter, "The Meaning and Validity of Quality of Life Judgments," in Quality
of Life, pp. 85-86.
- William H. Bullock, "Assessing Burdens and Benefits of Medical Care,"
Origins, January 30, 1992, pp. 554.
- William E. May, et al., "Feeding and Hydrating the Permanently Unconscious
and Other Vulnerable Persons," in Quality of Life, p. 200.
- Richard A. McCormick, Corrective Vision, Sheed & Ward, Kansas
City, MO, 1994, p. 232.
- McCormick, Corrective Visions,p. 232.
- Robert Barry, "The Ethics of Providing Life-Sustaining Nutrition and
Fluids to Incompetent Patients," Journal of Family and Culture, Summer
1985, p. 25.
- Albert S. Moraczewski, "The Moral Option Not to Conserve Life under Certain
Circumstances," in Conserving Human Life, Russell E. Smith, ed.,
Pope John XXIII Center, Braintree, MA, p. 257. Most Catholic theologians
agree that medically assisted nutrition and hydration is a medical treatment
subject to the same moral standards as other treatments. See, for example,
Brodeur, "Feeding Policy Protects Patients' Rights, Decisions," p. 43; Richard
A. McCormick, The Critical Calling: Reflections on Moral Dilemmas Since
Vatican II, Georgetown University Press, Washington, DC, 1989, pp. 380-381;
and Kevin D. O'Rourke and Jean deBlois, "Removing Life Support: Motivations,
Obligations," Health Progress, July-August 1992, pp. 20-27, 38.
- This argument is made by several theologians, including Benedict M. Ashley,
"Ethical Obligations," in Scarce Medical Resources and Justice, Pope
John XXIII Center, Braintree, MA, 1987, pp. 159-165; Kevin D. O'Rourke,
"On the Care of 'Vegetative' Patients: A Response to William E. May's 'Tube
Feeding and the Vegetative State': Part One," Ethics and Medics,
April 1999, pp. 3-4; Kevin D. O'Rourke, "On the Care of 'Vegetative' Patients:
A Response to William E. May's 'Tube Feeding and the Vegetative State':
Part Two," Ethics and Medics, May 1999, pp. 3-4; and Patricia A.
Talone, Feeding the Dying: Religion and End-of-Life Decisions, Peter
Lang, New York City, 1996, p. 21.
- National Conference of Catholic Bishops, pp. 22-23.
- See, for example, New Jersey Catholic Conference, "Providing Food and
Fluids to Severely Brain Damaged Patients," Origins, January 22,
1987, pp. 582-584.
- Multi-Society Task Force on PVS, pp. 1,576-1,577.
- See, for example, Orville Griese, "Feeding the Hopeless and the Helpless,"
in Conserving Human Life, pp. 147-232, and William E. May, "Tube
Feeding and the 'Vegetative State,'" Ethics and Medics, January 1999,
- McCormick, "To Save or Let Die," pp. 175-176.
- Moraczewski, p. 64. For a discussion of ways of dealing with the emotional
responses to such decisions of patients, family members, and medical personnel,
see Gail Povar, "Withdrawing and Withholding Therapy: Putting Ethics into
Practice," Journal of Clinical Ethics, Spring 1990, pp. 50-56.
- Texas Catholic Bishops and the Texas Conference of Catholic Health Facilities,
"On Withdrawing Artificial Nutrition and Hydration," Origins, June
7, 1990, pp. 54.
Copyright © 2001 by the Catholic Health Association of the United States
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