On March 20 of this year Pope John-Paul II addressed a gathering of physicians and theologians on the issue of care for patients in a chronic or persistent “vegetative state” (pVS). This is a condition, often referred to as “brain death,” brought on by severe damage to the cerebral hemispheres. It leaves the patient with no capacity for selfawareness or ability to relate to others. Since the brainstem is intact, however, autonomic and motor reflexes function normally. The patient experiences ordinary sleep-wake cycles and often emits sounds that can be misunderstood as attempts to speak. Where this so-called vegetative state has persisted for more than a few months, there are no documented cases of full recovery. (The term “vegetative” refers to the condition; it does not imply that the patient is less than human or is no longer a “person” in the full sense.)
The Pope was responding, at least in part, to the much-publicized case of Terri Schiavo, a brain-damaged patient whose husband has sought to have her feeding tube removed. Although she has been diagnosed .as being in a “vegetative” state, this has yet to be clearly demonstrated. The rule of thumb should be that where there is doubt, nutrition and hydration should definitely be continued. In cases of actual PVS, removal of nutrition and hydration leads quickly to death. Many ethicists argue that such removal is morally acceptable, since the underlying cause of death is the irreversible medical condition that prevents the patient from taking food normally.
Since the early 1980s it has been clinically established that withholding food and hydration from terminally ill patients—that is, those who are actively engaged in the dying process—can be beneficial. It allows the build-up of nitrogen wastes that produce azotemia, a natural analgesic, and can enable the patient to slip into a coma and die peacefully. On the other hand, continuing to provide food and water through intubation in terminal cases can increase the patient’s sense of pain and suffering, without offering a proportional benefit.
The question raised by the Schiavo case, as by the Pope’s declaration, is whether it is ever morally and medically appropriate to remove food and hydration from a patient in PVS. Such patients are not, in the strict sense, terminally ill; that is, they are not actually dying, even where there is no chance for recovery. If they are provided with food and water, they can live for months or even years. Yet their physical existence is preserved only by life-support technology and they remain in a state of permanent unconsciousness. If that technology were not available, such patients would quickly die, since they are incapable of feeding themselves or of being fed orally.
Catholic moral theologians have long debated whether providing nutrition and hydration to patients in PVS falls into the area of “ordinary” or “extraordinary” means. If the former, then such treatment is ethically mandatory; if the latter, then, weighing burdens against benefits, it may be morally appropriate to withdraw all life-support and allow the patient to die. The Pope’s declaration made it clear that he locates the providing of food and water in the realm of ordinary means, and therefore it is morally obligatory in cases of PVS. Many Catholic ethicists, however, feel otherwise. They argue that there comes a point in a person’s life where administering artificial nutrition and hydration merely hinders the patient from attaining what we request in our Orthodox prayers: a “peaceful separation of soul and body,” “a painless, blameless and peaceful” end to earthly life and the passing on of the person to the ultimate end of human existence, which is eternal communion with God in the Kingdom of Heaven.
In light of those prayers and the Orthodox perspective on the mystery of death, we need to have as our primary concern the best interests of the patient. No one wants to lose a beloved mend or family member. Accordingly, there is a strong temptation (and often pressure) to do “all possible” to ward off death, even if it means preserving a minimal level of existence by purely artificial means. We need to ask, though, whether such actions serve the interests and well-being of the patient, or whether they derive from our own reluctance to accept the loss associated with death and to surrender the person into the hands of God.
This raises the question of the “quality” of the patient’s life. Often the decision to provide or withhold nutrition and hydration is made on the basis of a subjective judgment as to whether the patient’s existence is worth preserving. The issue has unfortunately been polarized between those who argue for “sanctity of life” criteria (life is inherently sacred, therefore it must be preserved at all costs) and those who argue for “quality” considerations (if that life is deemed worthless or pointless, then there is no obligation to preserve it).
This way of raising the question, however, is false and misleading. All human life is inherently sacred, and it is precisely that sacredness that invests it with its ultimate and indelible “quality.” This means, however, “there is a time to live and a time to die.” Death in a biblical perspective—a Paschal perspective—is no longer “the last enemy.” Death itself has been destroyed, and “we are given Life.” From the time of our conception until the end of our physical existence, the very purpose of our being is to allow the Holy Spirit to work within us the transformation from a “body of death” to “life in Christ,” a life that begins in the present age and endures through and beyond physical death, into the fullness of life in the Kingdom God.
When a person is dying—when “the soul is struggling to leave the body”—then, again, it may be morally permissible, even obligatory, to withhold nutrition and hydration, in order that death may come “naturally,” as a regretted end but a blessed beginning to a new order of life. Can we say the same of patients in PVS, who, technically, are not “terminal”?
All we can conclude, it seems, is this. Where there is no chance for recovery other than through God’s own miraculous intervention (which can occur at any point), then it seems reasonable to conclude that artificial means of life-support, including nutrition and hydration, may be morally withdrawn or withheld. The final judgment needs to be made, not by distinguishing “ordinary” from “extraordinary” means, but by weighing the possibilities for cure. Where further medical intervention is futile, and merely hinders the person in his or her struggle to die, then such intervention should be judged to be abusive rather than beneficial. “Medical heroics” in such a case are morally inappropriate.
Yet any decision to remove life-support, particularly in non-terminal cases such as PVS, must be taken as the fruit of ardent and “disinterested” prayer. This does not mean that we should expect that an answer to the question regarding appropriate treatment or non-treatment will be written on the wall. It means that members of the Church community—including the family, friends, and insofar as possible the medical team offer the patient to God through ceaseless intercession, asking for both clarity and charity in making what could be their final decision regarding that patient’s future and well-being.
In the final analysis, everything depends on our motive. Where our primary concern is for the ultimate healing and salvation of the person in question, then we can make decisions, even in a state of uncertainty and confusion, with the confidence that God, in His time and in His way, will indeed work for that person the paschal miracle that leads from a “dying life” through physical death, and into Life beyond.