The Vatican's Congregation for the Doctrine of the Faith says Catholic hospitals and health care facilities are morally obliged to provide nutrition and hydration to persons in a persistent vegetative state, even when that person's recovery is unlikely. If supplying such nutrition leads to other medical problems, the obligation ceases. Catholic belief in God urges us to fight to preserve our lives where we are able.

Moral obligations and health care
By Rev. Robert L. Kinast

My brother, who was diagnosed with multiple sclerosis 20 years ago, lives in a nursing home. Although his mental abilities are unimpaired, many of the residents in the home have forms of cerebral palsy or stages of dementia which make normal communication extremely difficult.

While the residents receive outstanding care, it is almost impossible to know their level of self-awareness or the feelings they experience.

This situation reaches an extreme with persons in a persistent vegetative state. In this case the cerebral cortex is unable to perform higher brain functions.

With the aid of life-support technology such persons may live for a long time. However, the quality of their personal life experience and the very meaning of human life that is dependent on machines are debatable issues, slanted unfairly perhaps by the very term "vegetative."

The most publicized and controversial instance of a person in this condition was the situation of Terri Schindler Schiavo a few years ago. Her husband insisted that she did not want to be kept alive artificially and requested that her feeding tube be removed. Her parents objected, arguing that she was still alive and the withdrawal of nutrition would in effect starve her to death.

The disagreement was finally settled by the courts in 2005, but the legal resolution did not answer the moral question of whether it is obligatory to provide nutrition and hydration to someone in this state.

Pope John Paul II addressed that question prior to the court ruling. In a 2004 speech to an international congress on this very topic, he declared that nutrition and hydration, even when administered artificially (for example, through a feeding tube), constitute ordinary care even for persons in a persistent vegetative state.

In view of the Terri Schindler Schiavo case and the statement by Pope John Paul II, the U.S. bishops requested a clarification from the Vatican Congregation for the Doctrine of the Faith on two questions.

The first question was whether caregivers are morally obliged to administer food and drink to a person in a persistent vegetative state, with the exception of someone who could not assimilate the nutrition or who would experience significant physical discomfort as a result.

The congregation's response was yes. It further clarified that such nutrition, even if administered artificially, is an ordinary and proportionate means of preserving human life. The assumption underlying this decision is that a person in a persistent vegetative state is truly alive and retains both the dignity and right to life which Catholic teaching upholds. Only when such feeding no longer achieves its purpose does the obligation cease.

The response to this question adds the observation that providing such nutrition prevents suffering and death by starvation and dehydration --- a point which some medical commentators dispute, namely, that withdrawing nutrition from a person in this condition amounts to starving them to death.

The second question which the U.S. bishops posed touched on a related medical point. They asked whether nutrition and hydration supplied by artificial means could be discontinued when competent physicians judge with virtual certainty that the patient will never recover consciousness.

The congregation said no. The reason is that a patient in a persistent vegetative state is still a human person with fundamental human dignity who deserves ordinary and proportionate care, even if it is supplied artificially.

Underlying this judgment is the conviction that nutrition and hydration do not constitute medical treatment but rather normal human sustenance. If they were a form of treatment, they may well be considered extraordinary means under the circumstances.

How authoritative are these decisions?

The Congregation for the Doctrine of the Faith is the primary agency of the Vatican for maintaining the integrity and orthodoxy of Catholic belief and practice. Its role is to provide clarifications on disputed questions and ambiguous situations and to seek clarifications from theologians and church groups whose positions may be erroneous.

In addition, when issuing a formal teaching, the congregation ordinarily obtains the approval of the pope. In the present case Pope Benedict XVI formally approved the responses of the congregation. Consequently, while this decision is not infallible or guaranteed with dogmatic certainty, it represents the authoritative teaching of the magisterium and should be followed by all Catholics.

The end result is that Catholic hospitals and health care facilities are morally obliged to provide nutrition and hydration to persons in a persistent vegetative state and may not withdraw such nutrition even when it is unlikely that the person will recover.

If, on the other hand, supplying such nutrition is ineffective, leads to other medical problems, actually causes physical pain or cannot be administered because of the locale and unavailability of necessary resources, the obligation ceases.

Although the number of persons in a persistent vegetative state is relatively small, the decisions about their care are as important as in any other case. And the moral obligations, though more ambiguous and complex than many other cases, are just as real.

The Vatican's response to the U.S. bishops has clarified those moral obligations.

Father Robert Kinast is a pastoral theologian in Prairie Village, Kan.

'Don't keep him alive for me ...'
By Barbara Stinson Lee

The message came to me that my father was dying in a hospital in Phoenix in March 1988. I was on assignment in Price, Utah, 120 miles south of Salt Lake City. As I stood in the convent of the Daughters of Charity, my sister Elizabeth and my brother Frank told me of the options the doctors offered my family gathering from California, Utah and Illinois.

Dad was 75. A retired air traffic controller and one-time crime reporter for the New York Sun newspaper, his life had been filled with stress. He smoked three packs of cigarettes a day until strokes killed the cravings. He was a resident at a long-term care facility in Phoenix for two years.

Mother visited him daily. The six of us adult children made regular trips home, timing our visits so we wouldn't overwhelm him. We didn't want him to be too lonely or to leave Mother without the care and compassion of her children.

Our options were few that night. Dad was bleeding into his brain. Everyone was on the way home except for my younger sister Joan who was flying standby and lost somewhere between Chicago and Phoenix. I had been meeting with people and doing interviews as I worked my way down to Price in the days before cell phones.

"The doctor said they can do some surgery," Frank said. "They can maybe stop the bleeding and try to keep him alive until you and Joanie get here. What do you think?"

Daughter of Charity Sister Barbara Mulvehill stood with me. We cried together.

Finally, the only words I could think of came out of my mouth: "Don't keep him alive for me. I don't know about Joanie. But for me, tell the doctors to make him comfortable, and let him go to God."

Dad's wishes were known. He did not want any more strokes or struggles. With 12 years of health care experience behind me, largely in rehabilitation and physical therapy, I knew how my father was struggling --- and would struggle --- if his life were prolonged.

I can't count the number of times I've seen people go through scenes like my own: parents making heart-wrenching decisions about their teenage children mangled beyond recovery in automobile accidents; wives trying to determine if their husbands would want to live with a severe brain injury after industrial accidents; my own mother watching each stroke take more and more of my father's self away.

I knew about living wills and end-of-life directives from my previous job. But did Dad have a living will? Where was it? Was it signed? What would he want us to do? Does he want one more day with Mother, to whom he'd been married for 47 years?

Even if a person has a living will or other type of advanced directives, the questions remain. The doctors know what they must do --- follow the instruction on the advanced directives --- but what if one or two children might be able to have a few last moments with their father if there was just a little "interference?"

My father died that night, surrounded by Mother and four of his six children, some in-laws and grandchildren. Joan was stuck in Las Vegas where Dad had been working when she was born in Phoenix. I was in a convent in Price, praying.

Barbara Stinson Lee is editor of Intermountain Catholic, newspaper of the Diocese of Salt Lake City.

The balancing act involved in making life-and-death medical decisions
By Brian M. Kane

Penicillin, polio vaccines, kidney and heart transplants, and artificial nutrition and hydration were all unknown a century ago. Today we have longer life spans, better health and more medical choices than our ancestors.

For all of these scientific wonders, though, we are still left with some difficult moral choices pertaining to these advances.

Karen Ann Quinlan was at the center of the first of a series of legal cases that clarified the right of patients to make their own decisions about their medical care.

Quinlan suffered severe brain damage following an accident and was kept alive through a respirator and by artificial nutrition and hydration. After a lengthy legal battle, the New Jersey Supreme Court ruled in 1976 that her parents could assert her right to choose "to permit this non-cognitive, vegetative existence to terminate by natural forces" by discontinuing medical treatment.

It is important to note that the court did not indicate how the moral decision about ending treatment was to be made, just that individuals have a legal right to do so.

Joe and Julia Quinlan, Karen's parents, thought and prayed about the decision as a family. In consultation with their pastor, Father Tom Trapasso, they chose to remove Karen's respirator and continue her artificial nutrition and hydration.

Their moral choice was based upon the Catholic distinction between ordinary and extraordinary care.

---Ordinary care involves treatment that provides a benefit to the patient without an overwhelming burden.

---Extraordinary care involves a disproportionate burden in relation to the benefit.

The Quinlans thought that the invasive nature of the respirator was extraordinary while the nutrition and hydration were not.

After their decision, Karen lived another 10 years.

Catholics today are faced with the same dilemma as the Quinlans. Legally, courts have firmly placed the right of medical decision-making in the hands of each patient. Yet from a Catholic viewpoint, this choice has limitations.

Catholic belief in God, who has created us in his image, urges us to fight to preserve our lives where we are able. When the cost of such a struggle becomes unbearable, however, we are not obligated to simply stay alive for its own sake.

It may be best to simply acknowledge that what we can do is not enough to outweigh what we cannot do.

While those of us who are American, for example, have the legal right to act, as Catholics we have the ultimate responsibility for how we act. The distinction is one that we should recall as we think and pray about our own medical decisions.

Brian M. Kane, a professor of moral theology and chairperson of the Philosophy and Theology Department at DeSales University, Center Valley, Pa., is the author of "The Blessing of Life: An Introduction to Catholic Bioethics;" Lexington Books, 2008.