Euthanasia, defined as “an action or omission which of itself and by intention causes death, with the purpose of eliminating all suffering” (Evangelium Vitae, #64) is objectively evil and indeed, opposing it is a core component of the culture of life. It is listed on par with murder, genocide, and abortion in Gaudium Et Spes and Pope John Paul declared it to be “a grave violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person” (Evangelium Vitae #65).
This seems clear and unambiguous. And yet, it is often not. Many remain confused about whether merely allowing someone to die, by withholding certain treatments, is akin to euthanasia, and the statements from the Church in specific cases are often vague and sometimes even contradictory. Here is the key issue: there is a profound difference, well grounded in Catholic moral teaching, between killing somebody and discontinuing treatment that offers no hope of recovery. From the Catechism (#2278):
“Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of “over-zealous” treatment. Here one does not will to cause death; one’s inability to impede it is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected.”
The 1980 Declaration on Euthanasia had this to say:
“One cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide [or euthanasia]; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected.”
And finally, John Paul fleshes it out in Evangelium Vitae:
“Euthanasia must be distinguished from the decision to forego so-called “aggressive medical treatment”, in other words, 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. In such situations, when death is clearly imminent and inevitable, one can in conscience “refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted”.Certainly there is a moral obligation to care for oneself and to allow oneself to be cared for, but this duty must take account of concrete circumstances. It needs to be determined whether the means of treatment available are objectively proportionate to the prospects for improvement. To forego 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.”
This reflects a very old tradition. As far back in the 4th century, St. Basil wrote:
“Whatever requires an undue amount of thought or trouble or involves a large expenditure or effort and causes our whole life to revolve, as it were, around solicitude for the flesh must be avoided by Christians.”
The distinction between proportionate/ordinary care (which was morally obligatory) and disproportionate/extraordinary treatment (which was not) was worked out in detail by a group of 16th Century moralists, including Domingo Bañez and Francisco de Vitoria. When Vitoria was asked if a sick person who refused to eat be guilty of suicide, he answered:
“If a patient is so depressed or has lost his appetite so that it is only with the greatest effort that he can eat food, this right away ought to be reckoned as creating a kind of impossibility, and the patient is excused, at least from moral sin, especially if there is little or no hope of life.”
In modern times, and in modern medical circumstances, Catholics moralists have arrived at similar conclusions. The eminent Jesuit moralist Gerald Kelly concluded in the 1950s that nobody was obliged to use any means (natural or artificial) if there was no reasonable hope of overcoming the patient’s condition. Basically, intervention can be judged extraordinary and disproportionate for a host of reasons, including if it is deemed too expensive, unlikely to work, is associated with great suffering, or might save the patient’s life at too great a psychological, spiritual, or interpersonal cost.
It usually boils down to specific cases. Some cases revolving around difficult end-of-life issues are virtually ignored, with no public play, while others quite literally explode into the public debate. This seemingly random element is, in itself, unhealthy. A few years ago, Americans were consumed by the fate of Terry Schiavo, a woman in a persistent vegetative state who had her feeding tubes removed by court order, with the approval of her ex-husband, but against the wishes of her parents. More recently, Italians were focused on the case of Piergiorgio Welby, a man who was paralyzed and kept alive by a ventilator for nine years, before winning a legal battle to have it removed. Let’s look at each case in turn, fleshing out some of the core issues.
The Schiavo case
In the US, the Schiavo case was placed on the front burner of the so-called “culture war”, and where Catholic moral teaching seeme to take a back seat to political considerations. The pro-life movement in America seized the cause of Terry Schiavo, making a very rare venture outside the abortion issue. Of course, if the issue pertained to euthanasia per se, this would make sense. But it was not so black and white. And if not, why did the pro-life movement divert all its attention to this singular issue precisely at a time when the administration was conducting an unjust war and implementing torture? And then there were the more sinister developments. Sen. Mel Martinez wrote a memo salivating about the political opportunities this would present Republicans. Sen. Bill Frist, a doctor, engaged in a flawed TV diagnosis. Tom Delay threatened judges. George Bush took a rare break from his vacation. And Catholics who refused to toe the line laid out by these groups were accused of supporting murder by starvation.
Let’s try and cut through the subterfuge. Despite all the confusion, there were basically three key questions in the Schiavo case.
(1) Did Terry Schiavo’s husband act in accord with her wishes? He claimed she had told him that she would want to have such treatment withdrawn, even though it took him a while to recover this memory! We can never know the answer to this question, despite some of the venom spewed in his direction by the right. If he lied, and brought about her death simply be to rid of her (pure utilitarianism), then he will face God for his actions. But if he did not, then we are talking about an advance directive, and Catholics typically accept the legitimacy of such directives. As noted by Brother Daniel Sulmasy, an expert in the area:
“Broadly speaking, the Catholic Church supports advance directives, provided these are executed in a way that is consistent with Church teachings. In fact, if a person, motivated by a charitable desire to relieve others of the burdens such care might impose, executes an advance directive that states that he or she would not want artificial hydration and nutrition if ever in a state of post-coma unresponsiveness, then even the most conservative of Catholic moralists would conclude that the treatment should not be given.”
(2) Was Terry Schiavo aware of her surroundings? I believe that much of the emotional reaction to the Schiavo case stemmed from the TV pictures portraying a seemingly-aware woman who could react to human voices and other stimuli. Sadly, though, as the autopsy showed quite convincingly, she was indeed in a persistent vegetative state, with massive and irreversible brain damage, and was blind. In short, she was not aware of her surroundings. But even after the autopsy, pro-lifers like Fr. Frank Pavone refused to accept the inevitable, insisting that Schiavo responded to him, noting that “there is so much about the human brain we still don’t know“. Perhaps, but this does not help us tease out the moral implications of the case.
(3) Is it ever licit to withdraw nutrition and hydration from a patient in a persistent vegetative state? This is the crux of the issue. Convincing arguments can be made on both sides. Some have argued from the moral tradition of Bañez and Vitoria to the effect that providing food and water can sometimes be seen as extraordinary and disproportionate, justifying removal of tubes. If so, this would not be euthanasia.
Can we glean any lessons from specific past cases? Yes. One of the leading authorities in this area is Fr. John Paris S.J., a Jesuit bioethicist, who has written on this topic, relating how it played out in the United States over the past 50 or so years. [See: “The Catholic Tradition and the Use of Nutrition and Fluids,” by John J. Paris, S.J., in Birth, Suffering, and Death, edited by Kevin Wildes, 1992, Kluwer Academic Publishers]. Here are some of the highlights:
Daniel Cronin’s doctorate from the Gregorian in 1958 (he was later archbishop of Hartford, Mass.) noted that after a thorough review of over 50 moralists from Aquinas to the 1950s, “even natural means, such as taking of food and drink, can become optional if taking them requires great effort or if the hope of beneficial results (spes salutis) is not present“.
Gerald Kelly S.J., possibly the leading moralist of his day stated in 1950 that “no remedy is obligatory unless it offers a reasonable hope of checking or curing a disease“. He also said “”I’m often asked whether you have to use IV feeding to sustain somebody who is in a terminal coma. Not only do I believe there is no obligation to do it, I believe that imposing those treatments on that class of patients is wrong. There is no benefit to the patient, there is great expense to the community, and there is enormous tension on the family.”
Moralist Albert Moraczewski, O.P. noted “There appears to be no strict ethical obligation to provide nourishment by such technological interventions as intubation.”
Fr. Robert McManus, asked to advise Bishop Gelineau (Providence, Rhode Island) on a case involving a Catholic in a persistent vegetative state (PVS) for 2 years on the morality of removing life-sustaining nutrition and fluids, stated: “The medical treatments which are being provided the patient, even those which are supplying nutrition and hydration artificially, offer no reasonable hope of benefit to her. This lack of reasonable hope or benefit renders the artificially invasive medical treatments futile and thus extraordinary, and disproportionate and unduly burdensome. Moreover, the continuation of such medical treatments is causing a significant and precarious economic burden to [the patient’s] family. It must be unambiguously clear that the primary intention of removing what has been competently judged to be extraordinary means of artificially prolonging the patient’s natural life is to alleviate the burden and suffering of the patient and not to cause her death.”
Indeed, church guidelines in the United States often reflected these considerations. In 1987, the pro-life committee of the U.S. Catholic Conference declared that “laws dealing with medical treatment may have to take account of exceptional circumstances where even means of providing nourishment may be too ineffective of burdensome to be obligatory.” The Texas bishops adopted official guidelines in 1990, noting that patients in a persistent vegetative state can have such treatment withdrawn, and that this is “not abandoning the person…rather, it is accepting the fact that the person has come to the end of his or her pilgrimage and should not be impeded from taking the final step.” The 2001 Ethical and Religious Directives for Catholic Health Care Services of the USCCB notes that “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.” Although consistent with past advice, we can see a subtle shift in favor of the provision of nutrition and hydration as ordinary care, and this obligatory.
Pope John Paul II weighed in on this issue in May 2004. In a short allocution, he argued that artificial nutrition and hydration were “in principle, ordinary and proportionate, and, as such, morally obligatory, 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.”
But this statement should be interpreted not as some new innovation (as some have claimed), but as an affirmation of traditional teaching, with particular application to the circumstances of persistent vegetative states. Brother Daniel Sulmasy notes that a group of Catholic scholars met in 2004 to discuss this very issue in light of the pope’s speech. First, they noted, “in principle” does not mean without exception. All the pope is saying is that “for permanently unresponsive patients who are not not otherwise dying, tube feeding should be presumed to be ordinary and proportionate… unless its use would conflict with other grave responsibilities or would be overly burdensome, costly or otherwise complicated“. One implication of the pope’s statement is that the case for withdrawing tubes from patients in persistent vegetative states may be less clear than for other cases, such as those with diseases like terminal cancer, where tube feeding “will often result in great burden, no net benefit, and multiple complications“. But that does not rule out ever removing tubes. Note also the two conditions listed by the pope: providing nourishment, and alleviation of suffering. It could be argued that Terry Schiavo was not suffering.
As I noted, the area suffers from a grave lack of clarity. Was it wrong to remove nutrition and hydration from Schiavo, on the grounds that such provision should have been considered ordinary and thus obligatory? The pro-life movement, and many Catholics, certainly thought so. Or could it have been seen as extraordinary treatment, given that she was suffering from severe brain damage and was not cognizant of her surroundings? On this issue, the Church did not speak in a clear voice. The Florida bishops stuck to the traditional line, noting that there was a presumption to provide nutritional fluids, unless the continued use would become burdensome. Some individual US bishops, including Rigali and Burke, insisted on Schiavo’s right to life. Cardinal Keeler, chair of the U.S. Bishops’ Committee for Pro-Life Activities, argued that “..she is not in a coma, she is not on ‘life support’.. she needs only basic care and assistance in obtaining food and water.” Some Vatican officials also spoke out strongly, in fact, sometimes in stronger terms than their American counterparts. Cardinal Renato Martino called the outcome a grave step towards the legalization of euthanasia in the US. Bishop Elio Sgreccia also suggested that this was a case of direct euthanasia.
A disturbing outcome of the Schiavo case is the simple refusal of many in the pro-life movement to even acknowledge the nuances in this area. Instead, we were treated to the usual attacks against “dissident” priests like Fr. Paris and all who argued the traditional case were accused of complicity in murder by starvation. Richard M. Doerflinger, vice president of the Pro-Life Secretariat of the USCCB, believed that the 2004 allocution clinched the issue. Perhaps so. But as he himself noted, “at least before the pope’s allocution, that there was enough of a debate that a Catholic could reasonably choose either position.” Given this statement, it is grossly unfair to cast aspersions on those who supported Fr. Paris’s analysis.
The Welby case
Let’s skip briefly to Italy. In one sense, the Welby case is less of a grey area, as it revolves around a ventilator rather than nutrition and hydration. In 1957, Pope Pius XII, applied to traditional teaching to the use of ventilators, arguing that they could be deemed extraordinary treatment, and hence not morally obligatory. Commenting on this case in The Tablet, Fr. Paris notes that the Church has consistently applied this reasoning. In the case of Karen Ann Quindlin, who had a ventilator removed, moralist Richard McCormick SJ, stated that, from the Catholic tradition, there was no moral difference between removing a respirator, antibiotics or artificial feeding from Karen Ann Quinlan. The ventilator was switched off. And in a recent case, Archbishop Mario Conti of Glasgow, in discussing a case of a woman paralyzed from the neck down, said that:
“The principle here [the request for the withdrawal of a ventilator] is quite different from euthanasia. The request in this case is not for assisted suicide, rather it is for the discontinuation of a medical procedure which is burdensome to the patient.”
How did the Church react in Welby’s case? Again, there was great confusion, not helped by the fact that Welby himself viewed removing the ventilator as a form of euthanasia, and indeed, was an active pro-euthanasia campaigner in Italy. Welby claimed that the technology was artificially postponing his death and that was too burdensome (he could no longer eat or speak). The Vatican said clearly that the issue was whether or not the use of the respirator constituted extraordinary measures to postpone his life. But the Church did not take an unambiguous stance on this question. Accordingly, two top Vatican officials — Cardinal Javier Lozano Barragan, president of the Pontifical Council for Health Care Ministry, and Bishop Elio Sgreccia, president of the Pontifical Academy for Life — stated that they did not have enough information to make such a determination. Both Cardinal Barragan and Bishop Sgreccia argued that the doctor should decide. But this is clearly an unsatisfactory position, as the Catechism clearly says that “the decisions should be made by the patient if he is competent and able.”
Here’s a not-so-hypothetical example: what if the doctor decides to withdraw treatment based on the financial bottom line? In Texas, 6-month old Sun Hudson had his ventilator removed by a hospital, over the clear objections of his mother, who simply did not have the money necessarily to provide for his care. Is this the way we want to go? (By the way, this case received practically no attention, and there was no outcry, even though it coincided with the Schiavio case. Moreover, the law in question was signed by then-governor of Texax George Bush).
In the aftermath of the Welby case, Cardinal Carlo Maria Martini entered the fray, and appeared more sympathetic to Welby’s case, noting that he was fully lucid and that the breathing apparatus offered no possibility of improvement. Although Martini did explicitly condone Welby’s decision, he did say that is is generally up to the patient to decide whether the treatment is disproportionate or not. So, at the end of the day, closer to the Catholic tradition, but not that far either from Cardinal Barragan, despite the media playing up in-fighting in the Church over this issue.
So far, so nuanced. But it got a lot worse when Cardinal Camillo Ruini, papal vicar of Rome, refused to grant Welby a Catholic funeral. Although the Diocese of Rome stated clearly that it was being denied because of his long-time advocacy for legalized euthanasia, and not arising from the circumstances of his death, the damage was done. Welby’s widow made the point that the Church had not refused a Catholic funeral to the murderous dictator Pinochet. As Cardinal Martini hinted, “more attentive pastoral consideration” would have been helpful. And since when did the Church refuse Catholic funerals to all public figures who advocate abortion, euthanasia, torture and other intrinsically evil acts?
Going forward…
Why is the Church so circumspect about this issue? I think the answer is obvious. The distinction between euthanasia and withdrawal of extraordinary treatment can be an immensely subtle one, and there is still a lot of disagreement on where the line should be drawn. In the meantime, it often just looks too close to euthanasia for comfort. As noted by Gerald Kelly:
“I frankly hesitate to give a practical answer allowing the physician to discontinue the intravenous feeding as a means to end suffering. I fear the abrupt ceasing of nourishment to a conscious patient might appear to be a sort of ‘Catholic euthanasia’ to many who cannot appreciate the fine distinction between omitting an ordinary means and omitting a useless ordinary means.”
Richard McCormick was also well aware of the “misinterpretation and misuse of the Catholic principle“, believing that Americans would see the withdrawal of nutrition from Quinlan as akin to euthanasia. Also, moralist Charles McFadden, argued that “while the long-term use of artificial feedings could constitute a grave and non-obligatory burden, as a matter of practical medical advice he would never propose the removal of intravenous feeding once it had been instituted.” Why? There a risk of scandal, and that people would not understand nuaned distinctions and instead believe a person had been killed simply to alleviate suffering, i.e. euthanasia.
There is still far too much confusion in this area, and it is literally crying out for magisterial intervention. I think, in particular, there is a need to address the following three issues:
(1) Is there a moral difference between refusing to accept treatment, and ending treatment that has already begun? Advance directives give people the right to refuse certain treatments, and are licit within certain conditions. But under what circumstances can treatment be licitly withdrawn?
(2) How do advancements in the quality of medical care and treatment affect a tradition that was largely worked out in context of the 16th Century? Should the Church adapt some of its teachings to changing concrete circumstances? In particular, do modern circumstances mean that the provision of nutrition and hydration should always be considered ordinary care and hence morally obligatory, without exception?
(3) Can we discern an ever-unfolding emphasis in Church teachings on the God-given human dignity of every human person affecting this aspect of Church teaching, as it has many others? Influenced by a personalist ethic, the Church emphasizes the intrinsic, inalienable, dignity proper to human beings, created in the image and likeness of God, whereby every person is an agent of moral worth that cannot be treated as a mere object or as a means to an end. In recent times, the Church has broadened the scope of its culture of life teachings, by (among other things) greatly restricting the scope for the licit use of the death penalty, condemning torture as intrinsically evil, and viewing ever-narrower conditions for the justness of war. Does this general trend have implications for end-of-life issues? Can we argue that the old proportionate-disproportionate distinction places too much weight on “quality of life”, in a way that downgrades the human dignity or intrinsic worth of the person? John Paul, in Evangelium Vitae, does argue that the arguments for euthanasia are often based on utilitarianism, where society is ordered on the basis of “productive efficiency.”
In conclusion, the personal example of John Paul himself is worth noting. As he approached the end, he refused to go back to the Gemelli Hospital, where he would probably have been hooked up (yet again) to a respirator and feeding tube. Instead he said simply “Let me go to the house of the Father.” For just as euthanasia is wrong, so is the vitalism that attempts to cling to life at all costs.
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