“I should like particularly, to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act.”1
Those are the words of Pope John Paul II, speaking in March 2004 to an international congress held in Rome. The conference was on “Life-sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas,” and it was organized by the World Federation of Catholic Medical Associations and the Pontifical Academy for Life. The pope was able to cut through all the ethical dilemmas. Although he acknowledged that a patient in a persistent vegetative state, or PVS, “shows no evident sign of self-awareness or of awareness of the environment, and seems unable to interact with others or to react to specific stimuli,” he said that they should be kept alive indefinitely. Such patients, he insisted, “retain their human dignity in all its fullness” and “the loving gaze of God the Father continues to fall upon them.” For this reason, he said, it is obligatory to continue to provide them with food and water, even if this can only be done through a tube. The pope added that to withdraw the tube, knowing that it will lead to the death of the patient, is “euthanasia by omission.”
The pope supported his conclusion by arguing that some patients with PVS make at least a partial recovery, and, in the current state of medical science, we are still unable to predict with certainty which patients will recover and which will not. But here he seems to have been poorly advised. While it is true that in most PVS cases, we cannot definitively exclude the possibility of recovery, modern brain-imaging techniques do now enable us to know that in some PVS cases, the entire cortex has been destroyed. Then, no recovery is possible, for the cortex cannot reconstitute itself. Hence the argument for preserving the lives of these patients cannot be based on medical uncertainty.
No dilemmas for the pope, then, but plenty for Catholic hospitals around the world. In the United States, there are about ten thousand patients in a persistent vegetative state. Many of them are in one of the approximately six hundred hospitals run by the Catholic Health Association. Consistently with the views of some Catholic bioethicists, these hospitals have regarded artificial feeding as an “extraordinary means of life-support” and therefore as something that they are not obligated to provide.
Dr. Charles Daschbach, academic director at St. Joseph’s Hospital in Phoenix, Arizona, told the Arizona Republic that at St. Joseph’s decisions about whether to continue tube feeding were based on “balancing sufficient benefits to the patients against any burdens to patients and their families.” He added that the pope’s speech “was not sent as a part of the official church teachings.”2 Laurence O’Connell, director of the non-sectarian Park Ridge Center for Health, Faith, and Ethics in Chicago, put it more bluntly, describing the pope’s statement as “a stunner, to say the least.”3
A more puzzling statement came from Richard Doerflinger, a spokesman for the United States Conference of Catholic Bishops Secretariat for Pro-Life Activities. “To have the pope speak on this and speak his mind is something people on both sides of the question have been waiting for for years,” he said. But then he added, “It does not remove practical judgements about whether a feeding tube in an individual case is doing more harm than good.” Doerflinger didn’t explain how a feeding tube could harm patients who are completely unaware of anything that is happening to them.
If Catholic hospitals do attempt to implement the pope’s view, they will be heading for a collision with the principle of patient autonomy, long recognized as central to health-care ethics. Some patients sign statements indicating that they do not wish to be kept alive should they ever be in a persistent vegetative state. In the case of Nancy Cruzan, a young woman who had been in PVS for seven years, the U.S. Supreme Court ruled that feeding tubes are medical treatment and maybe withdrawn if there is evidence that that is what the patient would have wanted. The pope has now taken the opposite view. In his view, feeding tubes are “natural” and not medical treatment. Patients have a right to life, but apparently that is not a right that gives them any choice. They have to be fed, whether they like it or not.
Australia’s leading Catholic bioethicist, Father Norman Ford, seems to have taken a more humane view than the head of his own church. At the Rome conference at which the pope spoke, he argued that since PVS patients lacked the instinct to eat or drink and experienced loss of appetite, to give them food and water, far from being required by their dignity as human beings, actually “shows a lack of respect for them.” But that was before the pope spoke. Afterwards, Father Ford told The Tablet, the leading Catholic magazine in the United Kingdom: “I accept the teaching given by the Pope in his speech to congress participants.”4 That’s the trouble with being a bioethicist in an institution that doesn’t allow free speech within its own ranks.
1. The pope’s speech is available at http://www.vegetativestate.org/discorso_ papa.htm.
2. Austen Ivereigh, “US Hospitals in Dilemma over PVS Patients,” The Tablet, April 10, 2004; available at http://www. thetablet.co.uk/cgi-bin/citw.cgi/past-00174# Americas.
3. Cathy Lynn Grossman, “Pope Declares Feeding Tubes a ‘Moral Obligation,’” USA To day, April 1, 2004; available at http://www.usatoday.com/news/religion/2004-04-01-pope-usat_x.htm.
4. Ivereigh, “US Hospitals in Dilemma over PVS Patients.”
Peter Singer is DeCamp Professor of Bioethics at the University Center for Human Values at Princeton University. He is the author of Animal Liberation, Practical Ethics, Rethinking Life and Death, Writings on an Ethical Life, and, most recently, The President of Good and Evil: The Ethics of George W. Bush.