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William E. May

Michael J. McGivney Professor of Moral Theology

John Paul II Institute for the Studies of Marriage and Family at

The Catholic University of America

After giving a brief “historical background” to my involvement in this issue, I will  summarize responses from various sources to the question of providing food/hydration by tubal means to persons alleged to be in this condition prior to Pope John Paul II’s March 20, 2004 address; in particular, I will examine and criticize a major argument advanced by Catholic theologians to support the view that such provision of food/hydration constitutes extraordinary or disproportionate treatment and is hence not morally obligatory and then present the reasoning given by others, Catholic and non-Catholic, to support the claim that such provision is morally required and must be regarded as ordinary or proportionate means of preserving life. I will then consider Pope John Paul II’s address, some negative reactions it has received, and a defense of it. I will then offer a conclusion.

Historical Background

In my book Human Existence, Medicine and Ethics: Reflections on Human Life, published in 1977, I claimed, in commenting on the Karen Quinlan case, that there was no obligation “to use the means currently employed to prolong her death” and that it would be morally permissible for her parents and others to “remove the tubes necessary for her feeding, prevent dehydration by appropriate medical means, and attend to her in her dying moments.” [1] But in 1985 a study group of the Pontifical Academy of Sciences released a report on the artificial prolongation of life. In it were included “Medical Guidelines” which declared: “If the patient is in a permanent, irreversible coma, as far as can be foreseen, treatment is not required, but all care should be lavished on him, including feeding” (emphasis added). [2] I thus began to reconsider the position I had taken in 1977.

In 1986 Rev. William Gallagher, then president of the Pope John XXIII Center (now the National Catholic Bioethics Center), asked me to convene a group of moral theologians, moral philosophers, lawyers, medical doctors, and nurses to study the issues involved in providing food and hydration to the permanently unconscious and other vulnerable persons. I was then teaching at The Catholic University of America and I succeeded in having the following persons meet several times over several weeks to study the issue and to prepare a final paper: Benedict Ashley, O.P., Robert Barry, O.P., Msgr. Orville Griese, Germain Grisez, Brian Johnstone, C.Ss.R., Thomas Marzen, J.D., Bishop James McHugh, S.T.D., Gilbert Meilaender, Ph. D., Mark Siegler, M.D., and Msgr. William Smith. Some nurses who had spent many hours caring for individuals in the so-called persistent vegetative state also attended the meetings.

We learned that individuals in this condition are not suffering from a fatal pathology, that they are in a relatively stable condition and are capable of living for some time so long as they receive food and hydration. We learned that at the beginning they are capable of swallowing, but that feeding them orally takes a great deal of time and that using tubes to feed them lightens the burdens of their care-givers. We also learned that the cost of feeding them is very reasonable, and that they do not have to be kept in expensive institutions but can be cared for at home if someone is there to provide care and who can be helped by visiting nurses, etc.

As a result of the new knowledge, two of us who previously thought that tubally providing such persons with food and nutrition constituted extraordinary care and hence could be morally omitted, changed our minds—Germain Grisez and I. [3] Benedict Ashley, another member of the group who had previously judged it not morally required to provide food and hydration by tubal means, did not change his mind [4] and accordingly did not sign the final paper prepared and approved by the other participants in the meetings and subsequently published in the journal Issues in Law & Medicine under the title “Feeding and Hydrating the Permanently Unconscious and Other Vulnerable Persons.” [5] I will later summarize the reasoning advanced in this paper.

Responses by Various Sources to the Issue Prior to Pope John Paul II’s Address

Here I consider (1) recommendations of some professional bodies and bioethics centers; (2) major responses by bishops of the United States; (3) a summary and critique of the major argument advanced by Catholic theologians who claim that such feeding is not obligatory; and (4) a summary of the argument given by those who maintain that such feeding is morally obligatory unless it can clearly be shown to be futile.

1. Recommendations by Professional Bodies, etc.; PVS Patients, Consciousness, and Pain

During the 1980s and 1990s court cases involving termination of tubal feedings of PVS patients proliferated, eliciting responses from various professional organizations. In 1981 the Ethical and Judicial Council of the American Medical Association declared it ethical to withdraw all means of life support, including such feeding, “where a terminally ill patient’s coma is beyond doubt irreversible.” [6] The President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research addressed this issue in its 1983 monograph on foregoing life-sustaining treatments; it concluded that the decision to provide or forego tube feeding of PVS patients was best made by the patient’s surrogates and not by the courts; it likewise concluded that foregoing all treatment, including tubally administered food and hydration, was an ethically legitimate option. [7] Other organizations issuing guidelines favoring the withholding of tubal feeding from PVS patients included the Hastings Center (1987), the American Academy of Neurology (1989), and the American Medical Association (1990). [8] It should be noted that a significant number of the individuals who drafted statements of this kind think that “personhood” is lost if an individual is no longer capable of exercising cognitive abilities.

More importantly, as D. Alan Shewmon, M.D., a leading neurologist and an expert particularly on the neurology of the brain, has noted, the unquestioned acceptance among medical authorities that patients with widespread cortical damage are ipso facto unconscious and incapable of experiencing pain and suffering is not based on verifiable evidence but is accepted “because official neurology says so.” Shewmon concluded that upon critical examination the “evidence” alleged to support the claim that patients with widespread cortical damage are necessarily unconscious and incapable of feeling pain is “of an exclusively negative nature: patients with diffuse cortical destruction do not manifest clinical signs of awareness of self or environment. But there was no positive evidence that such patients are not inwardly conscious.” Continuing, he observed that “no one seemed concerned that perhaps what is eliminated by cortical destruction might be the capacity for external manifestation of consciousness rather than consciousness itself; in other words, that what is called “PVS” might in reality be merely a ‘super-locked-in’ state [a condition in which the person is indeed conscious but is utterly incapable of manifesting this externally].” [9] Shewmon then went on to say the following, in a passage of singular importance with respect to the question of pain experienced by PVS patients:

The more I reconsidered the matter, the more I began to realize that the supposed lack of evidence for consciousness was not even complete. For example, all treatises on the neurophysiology of pain traced the anatomical pathway from the cutaneous nociceptors centrally, invariably ending not at the cortex but at the thalamus. Patients with strokes involving somatosensory cortex lose tactile discrimination and joint position sense, but not the capacity to perceive and to localize pain. Thalamic injury, however, can cause a distressing form of central pain. In the pain literature it is clear that the cortex’s role in pain perception is merely modulatory and that the experience is mediated subcortically, but in the PVS literature these well known phenomena are systematically ignored. PVS patients often grimace to noxious stimuli and manifest primitive withdrawal responses. Advocates of the cortical theory write off such behaviors as mere brain-stem or spinal reflexes, but that dismissive attitude is based more on an apriori assumption than a scientific conclusion. [10]

2. Responses by U.S. Bishops

Prior to John Paul II’s address in March 2004 the universal Magisterium of the Church had not specifically addressed this question, but the bishops of the U.S. had given contradictory answers. Directive no. 58 of the Ethical and Religious Directives for Catholic Health Care Services (Nov. 1994) holds that one ought to presume that nourishment so provided be given such persons “as long as this is of sufficient benefit to outweigh the burdens involved to the patient.” Earlier, however, some individual bishops and the Texas Conference of Catholic Bishops had concluded that providing “food” through tubal means is futile and useless. The Texas Bishops, who did not provide extensive argument, believed that someone in PVS was “stricken with a lethal pathology which, without artificial nutrition and hydration will lead to death.” They held that withholding or withdrawing artificially provided food from such persons “is simply acknowledging the fact that the person has come to the end of his or her pilgrimage and should not be impeded [by artificially provided food] from taking the final step.” In short, the Texas bishops judged such provision of food futile or useless and hence not obligatory. [11] Some individual bishops issued statements of a similar nature. [12]

On the other hand, on March 24, 1992 the Administrative Committee of the National Conference of Catholic Bishops authorized the publication of a substantive document prepared by the Committee for Pro-Life Activities of the NCCB. This document surveyed somewhat extensively relevant medical literature dealing with the issue and different positions taken by moral theologians. In their review of theological opinions, the Pro-Life Committee explicitly stated that it did not find persuasive the rationale of some theologians that since persons in the PVS condition can no longer pursue the spiritual goal of life feeding them artificially is futile and/or unduly burdensome. In the conclusion of its paper, the Committee had this to say: “We hold for a presumption in favor of providing medically assisted nutrition and hydration to patients who need it, which presumption would yield in cases where such procedures have no medically reasonable hope of sustaining life or pose excessive risks or burdens.” [13]

It is noteworthy that John Paul II himself singled out this paper for praise in a talk to a group of U.S. bishops on their ad limina visit to the Vatican in 1998:

The statement of the U.S. bishops' pro-life committee, "Nutrition and Hydration: Moral and Pastoral Considerations," rightly emphasizes that the omission of nutrition and hydration intended to cause a patient's death must be rejected and that, while giving careful consideration to all the factors involved, the presumption should be in favor of providing medically assisted nutrition and hydration to all persons who need them. [14]

The Pennsylvania bishops had issued shortly before a somewhat similar document, replete with references to pertinent medical literature, on January 14, 1992. In its conclusion the bishops declared: “As a general conclusion, in almost every instance there is an obligation to continue supplying nutrition and hydration to the unconscious patient. There are situations in which this is not the case [e.g., when the patient can no longer assimilate the food and its provision is hence useless], but these are exceptions and should not be made into the rule.” In their judgment artificially providing food to PVS patients is “clearly beneficial in terms of preservation of life,” nor does it add a “serious burden” in the vast majority of cases. Consequently, it is in principle morally obligatory. [15]

Several individual bishops and other conferences of bishops issued statements reaching similar conclusions as the Pro-Life Committee and the Pennsylvania bishops. [16]

3. The Theological Position Claiming that Tubal Feeding of PVS Patients Not Morally Required

The leading proponent of this position is Kevin O’Rourke, O.P., who presented his position in several places from 1986 through 2001. [17] According to O’Rourke, his claim that it is not morally obligatory to provide food/hydration to the permanently unconscious is rooted in the teaching of Pope Pius XII. In an important address to a congress of anesthesiologists, Pius had this to say:

…normally one is held to use only ordinary means [to prolong life]--according to the circumstances of persons, places, times, and culture--that is to say, means that do not involve any grave burdens 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. On the other hand, one is not forbidden to take more than the strictly necessary steps to preserve life and health so long as he does not fail in some more important duty. [18]

O'Rourke claims that the Pope's emphasis on the spiritual goal of life

specifies more clearly the terms “ordinary” and “extraordinary.” A more adequate and complete explanation of  “ordinary” means to prolong life would be: those means which are obligatory because they enable a person to strive for the spiritual purpose of life. “Extraordinary” means would seem to be those means which are optional because they are ineffective or a grave burden in helping a person strive for the spiritual purpose of life. [19]

O'Rourke correctly interprets the teaching of Pius XII when he says that a means is extraordinary if it imposes a grave burden on a person and prevents him from pursuing the spiritual goal of life. But he errs greatly when he claims that a means is extraordinary when it is “ineffective...in helping a person strive for the spiritual purpose of life” and that a means is ordinary precisely and only insofar as it enables a person to strive for the spiritual purpose of life. Many people, including some seriously handicapped children and mentally impaired adults, are arguably incapable of pursuing the spiritual goal of life. People with very severe mental disabilities cannot do so because in order to do so a person must be able to make judgments and free choices. But these unfortunate human beings are still persons; their lives are still good, and it is good for them to be alive. If they should fall sick or be otherwise in danger of death, they surely have a right to “ordinary” care, and others have a serious moral responsibility to protect and preserve their lives unless the efforts to do so are themselves futile or excessively burdensome. Thus, for example, if an elderly person suffering from a malady that renders him incompetent and incapable of engaging in specifically human acts should suffer a cut artery and be in danger of dying because of loss of blood, it would surely be morally obligatory to stop the bleeding by appropriate means. Such means are surely “ordinary” or “proportionate.” Yet, on O'Rourke's analysis, they would be “extraordinary” inasmuch as they would in no way be effective in helping this person to pursue the spiritual purpose of life.

It is instructive to note that Charles E. Curran, in a book highly critical of the moral theology of John Paul II, appeals to the same text of Pope Pius XII in order to claim, falsely, that unlike Pius XII, John Paul has absolutized bodily integrity. [20]

Applying his understanding of Pius XII’s teaching to persons said to be in the PVS condition, O’Rourke maintains that since these individuals are not capable of pursuing the spiritual goal of life and since feeding them tubally is ineffective in helping them do so, then such feeding is not required. He maintains, in addition, as did the Texas Bishops in 1990, that such individuals are suffering from a “fatal pathology.” He likewise maintains that all one does by “feeding” such persons tubally is to preserve “mere physiological functioning.” His associate Benedict Ashley, O.P., shares this position. [21] I believe that this view at least tends toward dualism if it is not in essence dualistic, since it claims that all one preserves by providing food to such persons is mere physiological functioning. I think that what one preserves is the life of those persons, unities of body and soul and who are not, as he contends, suffering from a fatal pathology such as cancer or congestive heart disease that inevitably leads to death. [22]

O’Rourke consistently held this view from 1986 through 2003. Below I will comment on his views after March 20, 2004.

I think it relevant here to note O’Rourke’s later criticism of John Paul II’s teaching in Evangelium vitae on the withholding/withdrawing of treatments. In an essay sharply critical of the statement made by Bishop Elio Sgreccia on Vatican Radio on March 23, 2002 concerning the removal of life support in England from “Ms ‘B’”, [23] O’Rourke suggested that Sgreccia’s claims that her life support (a ventilator in this case) was grounded in John Paul II’s thought as set forth in Evangelium vitae:

Though he [John Paul II] admits that human life is not an absolute good, he insists that ‘no one can arbitrarily choose whether to live or to die; the absolute master of such a decision is the Creator alone’ (n. 47). This section of the encyclical seems to admit that in some circumstances the ability to prolong life will not be possible, but if life can be prolonged, it is not an unreasonable conclusion to say that it should be done. There is no consideration, in this section of the encyclical, of the ‘real condition’ of the patient, which is the context traditionally set forth for withholding or removing life support. [24]

O’Rourke’s conclusion is that Evangelium vitae failed to recognize that because of a patient’s condition treatments could be withheld/withdrawn even if the person were not in danger of death and that because of this failure the encyclical’s teaching—and Sgreccia’s view, which O’Rourke sees based on its teaching—departs from traditional Catholic thought.

4. The Position Holding That Artificially Providing Food to PVS Persons Is Obligatory

This view, like that of the Pennsylvania Bishops and the Pro-Life Committee of the National Conference of Catholic Bishops, holds that artificially providing food to permanently unconscious persons (those in the PVS state) is to be regarded ordinarily as morally obligatory insofar as it is neither useless nor unduly burdensome.

This was the position I and my collaborators--Robert Barry, O.P., Orville Griese, Germain Grisez, Brian Johnstone, C.Ss.R., Thomas J. Marzen, Bishop James T.McHugh, Gilbert Meilaender, Mark Siegler, M.D., and William B. Smith—developed in the article referred to earlier in this paper.

We began by articulating major presuppositions and principles, among them that human bodily life is a great good, that it is personal, not subpersonal, that it is inherently good not merely instrumentally so, that no matter how heavily burdened such life remains a good; (2) that human life, however heavily burdened, remains a good of the person and that remaining alive is never rightly regarded as a burden and deliberately killing innocent human life is never rightly regarded as rendering a benefit.

We held that withholding/withdrawing various forms of preserving life, including the provision of food and water by tubal means, is morally permissible if the means employed is either useless or excessively burdensome. We held that it is useless or relatively so if the benefits provided are nil or insignificant in comparison to the burdens imposed, and that it is excessively burdensome if benefits offered are not worth pursuing for one or more objective reasons: too painful, too damaging to the person’s bodily life and functioning, too restrictive of the patient’s liberty and preferred activities, too suppressive of the person’s mental life, too expensive, etc.

We acknowledged explicitly that “if it is really useless or excessively burdensome to provide someone with nutrition and hydration, then these means may rightly be withheld or withdrawn, provided that this omission does not carry out a proposal to end the person’s life but rather is chosen to avoid the useless effort or the excessive burden of continuing to provide the food and fluids.” [25] However, after examining the issue carefully, we judged that tubally providing food and hydration to the permanently unconscious and other vulnerable persons was neither useless nor excessively burdensome and that consequently it ought to be given. We thus concluded that:

in the ordinary circumstances of life in our society today, it is not morally right, nor ought it to be legally permissible, to withhold or withdraw nutrition and hydration provided by artificial means to the permanently unconscious or other categories of seriously debilitated but nonterminal persons. Rather, food and fluids are universally needed for the preservation of life, and can generally be provided without the burdens and expense of more aggressive means of supporting life. Therefore, both morality and law should recognize a strong presumption in favor of their use. [26]

We also argued that by caring for such persons in this way another good, that of human solidarity, was served. This point has been further developed by one of the co-authors, Germain Grisez who in a later work has said: “life-sustaining care for [persons] severely handicapped does have a human and Christian significance in addition to the one it would derive precisely from the inherent goodness of their lives. This additional significance is…profoundly real, just as is the significance of [a husband’s faithfulness to a permanently unconscious] wife, which continues to benefit not only the person being cared for but the one giving care.” [27]

Some, for example O’Rourke, argued that the expense entailed in feeding PVS patients must realistically be regarded as terribly burdensome in our society. He posed a question in his “Open Letter to Bishop McHugh” (who had held that the expense of feeding such persons is not excessive) that merits response. He said that McHugh was “disingenuous” in saying that “assisted nutrition and hydration…are not overly expensive” in view of the fact that “care in a hospital or long-term care facility costs anywhere from $600 to $1300 a day….” [28]

No one, we can presume, would want his family bankrupted in order to provide him with tubally assisted feeding. But does this mean that O’Rourke is correct? At present, the cost for taking care of PVS patients is usually covered in great part by insurance or other programs. But one cannot legitimately avoid excessive expense (if this does become an issue) by abandoning care for the person and by intentionally bringing his death about by starvation. There are morally legitimate ways to reduce the cost of care. Persons put into the situation of caring for a loved one in the PVS state or other conditions are not obliged to have them cared for in highly expensive hospitals or nursing homes (if insurance and governmental help are inadequate). They can remove them from these costly institutions, take them home and do the best they can with the help of such services as hospice care, volunteers from the parish or neighborhood, etc. The high standards of care possible in expensive institutions might not be possible, but one can still maintain solidarity with the person doing what one can, including providing food and nourishment by tubal means (not too difficult to do once begun, even at home). One does not have to endure undue financial burdens.

Pope John Paul II’s Address of March 20, 2004

Context and Key Themes

The Holy Father's Address came at the conclusion of an international congress entitled "Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas," co-sponsored by the Pontifical Academy for Life and the International Federation of Catholic Medical Associations. His address was thus based on the latest medical and scientific findings relevant to the "vegetative" state. These showed that this "state" is frequently misdiagnosed, that prognoses are far from reliable, and that the assumption that this state involves complete absence of unresponsiveness can be seriously questioned. In addition, scientific papers presented at the congress showed clearly that individuals said to be in the "persistent vegetative state" are not suffering from any fatal pathology or underlying disease that can cause their death, although they will, of course, die of dehydration if they do not receive food and water. [29] It should be noted, too, that even prior to this congress medical doctors acknowledged that persons in this condition can usually be fed orally at the beginning, but that feeding them by tubal means is far more convenient to their care-givers and is more efficient and that, if not fed orally, the ability of persons in this state to take food orally gradually atrophies. [30]

Among the principal themes developed by John Paul II in his Address are the following:

1.“A man, even if seriously ill or disabled in the exercise of his highest functions, is and always will be a man, and he will never become a ‘vegetable’ or an ‘animal.” (no. 3; emphasis in the original).

2. The right of the sick person, even one in the vegetative state, to basic health care. Such care includes "nutrition, hydration, cleanliness, warmth, etc." and "appropriate rehabilitative care" and monitoring "for clinical signs of eventual recovery" (no. 4).

3. The moral obligation, in principle, to provide food and water to persons in the "vegetative" state by tubal means: "I should like to underline how the administration of food and water, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering" (no. 4, emphasis in the original).

4. The need to resist making a person's life contingent on its quality: “it is not enough to reaffirm the general principle according to which the value of a man's life cannot be made subordinate to any judgment of its quality…it is necessary to promote the taking of positive actions as a stand against pressures to withdraw hydration and nutrition as a way to put an end to the lives of these patients" (no. 6; emphasis in original).

5. The principle of solidarity: "It is necessary, above all, to support those families who have had one of their loved ones struck down by this terrible clinical condition" (no. 6; emphasis added).

Some comments on the address

Although the immediate context for the Pope’s remarks was a conference on the vegetative state, similar ethical questions arise in the case of other patients, e.g. those suffering from advanced dementia, severe stroke, quadruple amputees, etc. Hence, the Pope’s speech is of wide relevance to Catholic healthcare professionals. In addressing these issues in the form of an allocution to a gathering of healthcare professionals, John Paul II followed the example of his recent predecessors, most notably Pius XII, who used similar contexts in exercising their ordinary authority to speak on ethical issues.

John Paul II emphasizes that the providing of food and water even by artificial means is to be regarded “in principle”(emphasis added) “‘ordinary’ and ‘proportionate’ and as such morally obligatory.” Thus although such provision is obligatory in principle, the Pope allows for those cases in which the provision of nutrition and hydration would not be appropriate, either because they would not be metabolized adequately, or because their mode of delivery would be gravely burdensome.

As the Australian bishops have noted, the Pope’s statement does not explore the question whether artificial feeding involves a medical act or treatment with respect to insertion and monitoring of the feeding tube. While the act of feeding a person is not itself a medical act, the insertion of a tube, monitoring of the tube and patient, and prescription of the substances to be provided, do involve a degree of medical and/or nursing expertise. To insert a feeding tube is a medical decision subject to the normal criteria for medical intervention. [31] I bring this up because some may claim that, since providing food/water by tubal means requires a medical act to insert the tube, such feeding is itself a medical treatment and not an act of caring. This is not true. But the insertion of a feeding tube, particularly through enteral and not perienteral means, is neither futile nor burdensome in almost all cases.

Some Negative Responses to This Address

Among the principal negative responses to John Paul II’s Address were the following: it marked “a significant departure from the Roman Catholic bioethical tradition,” [32] it was not in conformity with the 1980 Vatican Declaration on Euthanasia (Iura et bona), [33] and was not so primarily because it imposes excessively severe burdens on the families of such persons. [34] Thus John Paris, S.J., claimed that the pope’s talk ran counter to over 400 years of Church teaching, that it mandated use of excessively  burdensome means, that it was probably written not by the pope but by Bishop Elio Sgreccia, who “represents the radical right-to-life segment of thinking.” [35] Edward Sunshine found the Pope’s address so utterly incompatible with the 1980 Declaration on Euthanasia that it is “merely an assertion of ecclesiastical authority, with little grounding in reason,” [36] and John Tuohey likened it to a faulty thesis proposal by a graduate student ignorant of traditional Catholic teaching. [37] The well known Boston College moral theologian Lisa Sowle Cahill asserted apodictically that John Paul II was not the author of the document and like others contended that it is simply incompatible with traditional Catholic teaching. [38]

So far as I know, O’Rourke has not published any essay dealing with this issue since March 20, 2004. However, on April 26, 2005 I took part with him in a debate over the question for the priests of the Archdiocese of Detroit. O’Rourke did not have a prepared paper but he distributed a summary of his views in a print-out of a power-point presentation. In the course of this debate O’Rourke at times seemed to say that he had abandoned his earlier rationale for not providing food/hydration by tubal means to persons in the so-called persistent vegetative state based on the futility of doing so insofar as it would not enable such persons to pursue the spiritual goal of life. Nonetheless, one of the major points noted in his print-out and in his remarks was his colleague Benedict Ashley’s assertion that “the human body is human precisely because it is made for intelligence” and is thus “subordinate to the good of the immaterial and contemplative intelligence,” with the implied conclusion that all interventions prolonging bodily life are not obligatory if one can no longer use intelligence to pursue the spiritual goal of life.

Moreover, during the debate, he sought to rebut my claim that, if his interpretation of Pius XII’s statement were correct, then there would be no obligation to stop the bleeding of a trisomy 13 baby and others severely disabled mentally because doing so would not “enable” them to pursue the spiritual goal of life. He claimed that such individuals are still capable of “affection.” This may well be true; but dogs and cats are capable of ‘affection.” But this is far cry from the ability to engage in human acts, an ability O’Rourke and Ashley require, i.e., acts requiring not merely “cognitive/affective” abilities [which, like babies, chimpanzees and dogs have] but intelligence and free choice.

During the debate he explicitly argued that feeding/hydrating pvs patients  by tubal means was disproportionate/extraordinary because of the burdens doing so imposed on their care-givers. He also made it clear that he thought the March 20 2004 address with incompatible both with the Declaration on Euthanasia and John Paul II’s later address of November 12, 2004.

From this we can see that the principal criticisms of John Paul II’s address by Catholic ethicists are that it is incompatible with traditional Catholic teaching, including his own address of November 12, 2004, and that it imposes excessive burdens on the families of the permanently unconscious. I will thus focus on these criticisms in my defense of the document.

Defense of John Paul II’s Address

1. Compatibility of the March 20 Address with "Traditional Catholic Teaching"

Prior to his address in 2004 John Paul II had issued a major Encyclical explicitly concerned with life issues, Evangelium vitae, in 1995. In it he explicitly appealed to the 1980 Declaration on Euthanasia (Iura et bona) issued by the Congregation of the Doctrine of the Faith, declaring, “Euthanasia must be distinguished from the decision to forgo… medical procedures which no longer correspond to the real situation of the patient, either because they are by now disproportionate to any expected results or because they impose an excessive burden on the patient and his family…. To forgo extraordinary or disproportionate means is not the equivalent of suicide or euthanasia; it rather expresses acceptance of the human condition in the face of death” (Evangelium vitae, 65). Thus John Paul II obviously agrees that, whenever medical treatment or the provision of nutrition and hydration is withheld or withdrawn for legitimate reasons (futility, burdensomeness), this is not euthanasia. In his 2004 address he reaffirms the traditional teaching of the Church that only ordinary or proportionate means to sustain life are morally obligatory, and he uses the traditional criteria to determine whether means are ordinary or not: the ratio of benefit to burden and effectiveness in providing care for the patient. His teaching in no way requires that tubally assisted feeding and hydration be maintained at all costs, but only when the benefits such assistance provides are present and no excessive burdens are imposed. If in particular instances such feeding/hydration would not effectively preserve life or alleviate suffering it would lack its beneficial effect and would be futile.

Some months after his March 20, 2004 address, as noted above, John Paul delivered another address on November 12, 2004 to participants in the 19th International Conference of the Pontifical Council for Health Pastoral Care. In it he once again reaffirmed the Catholic tradition according to which aggressive treatment, i.e., treatment that “is ineffective or obviously disproportionate to the aims of sustaining life or recovering health.” He then went on to speak of the need to continue “palliative care” especially for patients with terminal diseases. [39] This address is in perfect conformity with, and in no way contrary to, his teaching on March 20 of the same year on the obligation, in principle, to provide food and hydration to the permanently unconscious “insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering” (March 20 address, no. 3; emphasis added).

In summary, the Pope’s statement is an application of traditional Catholic teaching, and says neither that nutrition and hydration must always be given, nor that they are never to be given, to unresponsive and/or incompetent patients. Rather, the Pope affirms the presumption in favor of giving nutrition and hydration to all patients, even by artificial means, while recognizing that in particular cases this presumption gives way to the recognition that the provision of nutrition and hydration would be futile or unduly burdensome.

His statement is fully compatible with the Ethical and Religious Directives for Catholic Health Care Facilities, whose directive no. 58 declares: "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" (emphasis added). This directive, which occurs in Part V, should be read in light of what the bishops have to say in their introduction to Part V. There they declare:

Some state conferences, individual bishops, and the NCCB Committee on Pro-Life Activities have addressed the moral issues concerning medically assisted hydration and nutrition…these statement agree that hydration and nutrition are not morally obligatory either when they bring no comfort to a person who is imminently dying or when they cannot be assimilated by a person's body.

Note that here the Bishops of the United States explicitly refer to the document prepared by the NCCB Committee on Pro-Life Activities and to documents of some state conferences. Of these the most developed is that of the Bishops of Pennsylvania. It will thus be suitable to see how John Paul II's Address relates to these documents.

Take first the document prepared by the NCCB Committee on Pro-Life Activities in 1992. That document challenged the claim, made by some theologians, that it was permissible to withhold/withdraw tubally assisted food and water from persons in the "vegetative" state because such persons are not able to pursue the "spiritual purposes" of life. The Bishops' Committee explicitly stated that it did not find these reasons "persuasive." Like John Paul II in his March 20 Address, it declared nutrition and hydration generally a form of "ordinary care," or at least ordinary means of preserving life, and that withholding/withdrawing such nutrition and hydration is a form of euthanasia by omission when the intent is to end life. [40]

As I noted earlier, John Paul II himself singled out this paper for praise in a talk to a group of U.S. bishops on their ad limina visit to the Vatican in 1998.

From this it is abundantly evident that the position taken by John Paul II in his March 20 address is completely compatible with traditional Catholic teaching as understood by this important committee of US bishops and, it can be added, the entire US Conference of Bishops Ethical and Religious Directives.

2. Does John Paul II Impose Excessively Grave Burdens on Families?

As noted, a major criticism of John Paul II’s address is that he in effect imposes grave burdens of the families of those whose lives are to be sustained by providing them with food and water by tubal means even when they are not consciously aware of themselves or others, and traditionally Catholic teaching has recognized that life-sustaining measures are disproportionate or extraordinary if they impose excessive burdens on patients or their families.

But simply providing the permanently unconscious with food and water does not impose burdens on families or other care-givers, just as the feeding of those paralyzed from the neck down or suffering loss of all limbs does not impose excessive burdens on care-givers. The burden they carry is not caused by the feeding but rather by the seriously debilitating condition of those for whom they care. But this is a burden that must in justice be accepted by others. Would those opposing John Paul II claim that we should stop feeding the demented, the paralyzed, quadruple amputees, and individuals who are simply “not with it”? Withholding or withdrawing tubally provided food and water would not eliminate the burden of care-givers; only the death of those cared for would end the burden. Here observations made by Germain Grisez are very relevant. He noted that as the permanently unconscious person’s loved ones witness what is done to provide food and other care they experience a great and undeniable burden. He then noted:

Of course, this burden will be eliminated if food is withheld, but only because the comatose person will be eliminated. Thus, to decide not to feed a comatose person in order to end the burden and his or her loved ones experience is to choose to kill that person in order to end the miserable state in which he or she now lives. [41]


Here I have shown, I believe, that John Paul II's March 20 address on the care that must be given to persons in the "vegetative" state is in no way incompatible with the "Catholic tradition," but that it is to the contrary, fully compatible with that tradition.

Moreover, John Paul II was keenly aware of the great hardship that families of PVS patients endure in caring for them. He thus outlined some of the important positive steps that may be taken to help these patients and their families, and “...to stand against pressures to withdraw hydration and nutrition as a way to put an end to the lives of these patients” (no. 6). John Paul II suggested the following concrete practical ways to help:

...the creation of a network of awakening centers with speci treatment and rehabilitation programs; financial support and home assistance for families when patients are moved back home at the end of intensive rehabilitation programs; the establishment of facilities which can accommodate those cases in which there is no family able to deal with the problem or to provide “breaks” for those families who are at risk of psychological and moral burnout (no. 6).

Such steps would demonstrate society’s concern and love for these seriously impaired individuals. From a specifically Christian perspective, they would give powerful testimony to the faithfulness and selflessness of Christian love. They would provide evidence of the genuine and disinterested character of Christian love, which continues to be expressed even when those who receive it can show no appreciation – even when they are apparently totally unaware of this loving presence. For in providing care only to those who can thank us and return the favor do we not already have our reward?


* A somewhat shortened form of this essay was published in
Medicina e Morale: Rivista internazionale di Bioetica 55 (Maggio/Giugno 2005) 533-555.

1. William E. May, Human Existence, Medicine and Ethics: Reflections on Human Life (Chicago: Franciscan Herald Press, 1977), pp. 150-151.

2. Report of the Pontifical Academy of Sciences on the Artificial Prolongation of Life, published in Origins, December 5 1985 as it appeared in the English edition of L’Osservatore Romano; reprinted in Conserving Human Life, eds. Albert Moraczewski, O.P., and Russell E. Smith (Braintree, MA: Pope John XXIII Medical-Moral Research and Educational Center, 1989), p. 306. The editors of Conserving Human Life note in a footnote that a more precise translation of the original Italian would be “If the patient is in a permanent coma, irreversible as far as it can be foreseen.”

3. In a lecture published in 1986, A Christian Ethics of Limiting Medical Treatment, in Pope John Paul II Lecture Series in Bioethics, Vol. 2, eds. Francis Lescoe and David Liptak (Cromwell, CT: Holy Apostles Seminary, 1986), pp. 49-50, Grisez had argued that it was not morally required to provide such persons with food and hydration.

4. Ashley closely collaborated with his fellow Dominican, Kevin O’Rourke, O.P., and shares his views. O’Rourke’s views on the subject will be taken up in detail later.

5. See Issues in Law & Medicine Vol. 3, No. 2 (Winter, 1987) 203-217. The authors were listed as: William E. May, Robert Barry, O.P., Msgr. Orville Griese, Germain Grisez, Brian Johnstone, C.Ss.R., Thomas J. Marzen, J.D., Bishop James T. McHugh, S.T.D., Gilbert Meilaender, Ph. D., Mark Siegler, M.D., and Msgr. William Smith. Subsequently 98 other scholars, including Paul Ramsey, Robert George, and Hadley Arkes signed the statement and their names are printed on pp. 212-217.

6. American Medical Association, Judicial Council, Current Opinions of the Judicial Council of the American Medical Association. Including the Principles of Medical Ethics and Rules of the Judicial Council (Chicago: American Medical Association, 1981), p. 9, par. 2.11.

7. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Deciding to Forego Life-Sustaining Treatment: Ethical, Medical, and Legal Issues in Treatment Decisions (Washington, D.C.: U. S. Government Printing Office, 1983), pp. 171-196.

8. Hastings Center, Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying  (Briarcliff Manor, N.Y.: The Hastings Center, 1987); American Academy of Neurology, “Position of the American Academy of Neurology on certain aspects of the care and management of the persistent vegetative state patient,” Neurology 39 (1989) 125-126; American Medical Association, Council on Scientific Affairs and Council on Ethical and Judicial Affairs, “Persistent Vegetative State and the Decision to Withdraw or Withhold Life Support,” Journal of the American Medical Association 263 (1990) 426-430.

9. D. Alan Shewmon, M.D., “Recovery from ‘Brain Death’: A Neurologist’s Apologia,” The Linacre Quarterly 64.1 (February, 1997) 59-60.

10. Ibid., 60.

11. Texas Conference of Catholic Bishops, “On Withdrawing Artificial Nutrition and Hydration” (May 7, 1990), in Origins: NC News Service 20 (1990) 53-55. It should be noted that 2 of the 18 members of the Texas Conference of Catholic Bishops refused to sign this statement, and one Texas bishop, René Gracída of Corpus Christi, published an extensive critique of it, “Interim Pastoral Statement on Artificial Feeding and Hydration: A Critique,” published originally in the May 25, 1990 edition of [Corpus Christi] Diocesan Press.

12. See, for example, The Most Reverend Louis Gelineau, Bishop of Providence, R. I., “On Removing Nutrition and Water from a Comatose Woman” (January 10, 1988), in Origins: NC News Service 17 (1988) 546-547.

13. Committee for Pro-Life Activities, National Conference of Catholic  Bishops, Nutrition and Hydration: Moral and Pastoral Reflections (Washington, D.C.: United States Catholic Conference, 1992), Publication No. 516-X, p. 7. The document was also printed in Origins: NC News Service 21 (1992) 705-711; the citation is found at 711.

14. John Paul II, "Building a Culture of Life," "Ad  Limina" Address to the Bishops of California, Nevada and Hawaii (October 2, 1998), Origins 18.18 (October 15, 1098), no. 4.

15. Pennsylvania Conference of Catholic Bishops, “Nutrition and Hydration: Moral Considerations,” in Origins: NC News Service 21 (1992) 542-553.

16. See, for example, the following: New Jersey State Catholic Conference, “’Friend-of-the-Court Brief to the New Jersey Supreme Court’: Providing Food and Fluids to Severely Brain Damaged Patients” (November 3, 1987), in Origins: NC News Service 16 (1987) 542-553; The Most Reverend James McHugh, Bishop of Camden, N. J., “Artificially Assisted Nutrition and Hydration” (September 21, 1989), in Origins: NC News Service 19 (1989) 314-316. The episcopal conferences of Missouri and Florida also issued statements on this matter, as did the Most Reverend John Myers of Peoria.  One researcher, Thomas Shannon (who himself holds that providing food artificially to PVS patients is not obligatory) sent a questionnaire to the ordinaries of US dioceses on the matter. 78 ordinaries responded, offering conflicting and contradictory directives, often prepared by diocesan bioethics committees or hospital committees within the diocese. Shannon summarizes his findings in an essay co-authored by James Walter, “The PVS Patient and the Forgoing/Withdrawing of Medical Nutrition and Hydration,” Theological Studies 49 (1988) 623-647, reprinted in Quality of Life: The New Medical Dilemma, ed. James J. Walter and Thomas A. Shannon (New York: Paulist, 1990) 203-223; the summary of Shannon’s survey is found on pp. 204-210.

17. See the following essays by O’Rourke: “The A.M.A. Statement on Tube-Feeding: An Ethical Analysis,” America 155 (1986) 321-333, 333; “Evolution of Church Teaching on Prolonging Life,” Health Progress 59 (1988) 28-35; “Should Nutrition and Hydration Be Provided to Permanently Unconscious and Other Mentally Disabled Persons?” Issues in Law & Medicine 5 (1989) 181-196,” “Open Letter to Bishop McHugh: Father Kevin O’Rourke on Hydration and Nutrition,” Origins: NC News Service 19 (1989) 351-352; “On the Care of ‘Vegetative’ Patients,” Ethics & Medics 24.4 (April, 1999) 3-4 and 24.5 (May, 1999) 1-2; with Benedict Ashley, O.P., in their book Health care Ethics (4th ed.: Washiington, D.C.: Georgetown University Press, 1997), pp. 421-426; with Patrick Norris, O.P., “Care of PVS Patients: Catholic Opinion in the United States,” Linacre Quarterly 68.3 (August, 2001) 201-217.

18. Pope Pius XII, “The Prolongation of Life: Allocution to the International Congress of Anesthesiologists” (November 24, 1957), in The Pope Speaks 4 (1958) 396.

19. Kevin O'Rourke, “Evolution of Church Teaching on the Prolongation of Life,” 32.

20. Charles E. Curran, The Moral Theology of Pope John Paul II (Washington, D.C.: Georgetown University Press, 2005), p. 114.

21. See their Health-Care Ethics, pp. 421-426.

22. A view somewhat analogous to O’Rourke’s is taken by James J. Walter and Thomas Shannon, “The PVS Patient and the Forgoing/Withdrawing of Medical Nutrition and Hydration,” Theological Studies 49 (1988) 623-647. See also Walter,  “Food and Water: An Ethical Burden,” Commonweal (1986) 616-619.

23. Sgreccia’s statement is available “On File,” Origins 31.42 (April 6, 2002) 2.

24. Kevin O’Rourke, O.P, “Ms ‘B’ and the Vatican,” National Catholic Bioethics Quarterly, 2.4 (Winter, 2002) 599.

25. May et al., “Feeding and Hydrating the Permanently Unconscious,” 209.

26. Ibid, 211.

27. Grisez, Difficult Moral Questions (Quincy, IL: Franciscan Press, 1997), p. 223.

28. O’Rourke, “Open Letter to Bishop McHugh: Father Kevin O’Rourke on Hydration and Nutrition,” 351-352.

29. On this see the brief review of the Congress's work given by Richard Doerflinger, "John Paul II on the 'Vegetative' State: An Important Papal Speech," Ethics&Medics 29.6 (June, 2004), 3. Doerflinger himself was a participant at the Congress. See also D. Alan Shewmon, M.D., "Recovery from 'Brain Death'" A Neurologist's Apologia," The Linacre Quarterly 64.1 (February 1`977) 59-60.

30. On this see The Merck Manual of Diagnosis and Therapy, ed. R. Berkow (15th ed.: Rahwaiy, NJ: Merck Sharp and Dohme Laboratories, 1987) 904-911.

31. Australian bishops, “Briefing Note on the Obligation to Provide Nutrition and Hydration,” 09-05-04, available at http://www.acbc.catholic.org.au/pdf/040903_briefing_note.pdf.

32. On this see Thomas A. Shannon and James J. Walter, “Implications of the Papal Allocution on Feeding Tubes,” Hastings Center Report 34.4 (July-August 2004), 18-20, at 18; see also Ronald Hamel and Michael Panicola, “Must We Preserve Life?” America (April 19-26, 2004) 6-13; John Tuohey, “The Pope on PVS: Does JPII’s statement make the grade?” Commonweal 131.12 (June 18, 2004).

33. Shannon and Walter, “Implications….”

34. See, for example, Sister Jean DeBlois, “Prolonging Life or Interrupting Dying? Opinions Differ on Artificial Nutrition and Hydration,” Aquinas Institute, Spring 2004 Newsletter, available at http://www.ai.edu, and John Paris, S.J. , ”No Moral Sense,” in an interview with Brian Braiker of Newsweek and available on http://www.msnc.mnsn.com/id/7276850/site/newsweek/print/1/displaymode/1098/.

35. See previous note.

36. Edward R. Sunshine, “Truncating Catholic Tradition,” National Catholic Reporter, April 8, 2004 at http://www.natcath.com/NCR­_Onlinearchives2/2005b/040805k.php.

37. Tuohey, “The Pope on PVS.”

38. Lisa Sowle Cahill, “Catholicism, Death and Modern Medicine,” America (April 25, 2005), pp. 14-17

39. The text of John Paul II’s Address of November 12, 2004 to this Conference is available at http://www.vatican.va/holy_father/john_paul_ii/speeches/2004/november/documents/

40. Committee on Pro-Life Activities, National Conference of Catholic Bishops, Nutrition and Hydration: Moral and Pastoral Reflections (Washington, D.C.: United States Catholic Conference, 1992), Publication No. 516-X.

41. Germain Grisez, “Should Nutrition and Hydration Be Provided to Permanently Unconscious and Other Mentally Disabled Persons”? Issues in Law & Medicine 5.2 (Fall, 1989) 171.

Copyright ©; William E. May 2005

Version: 23rd October 2005

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