Food and water for patients in vegetative state is obligatory, Vatican says

In any other setting, I would not dare to write this, but you mention having discussed your preferences with next of kin and I wonder whether you have discussed them with God as openly as with her. It has been my experience and observation that if you pray and ask 'why', God will answer that in some way, and if you pray that you cannot handle it and wish it to end, you will either be given the strength to handle it or it will be ended.

Despite the directive regarding water, food, and air for the sick, there is still no requirement to avail yourself of cures and treatments, nor is there likely to be. It simply is not the case that keeping you nourished so that your body has the strength to live if it should be God's will that you do or that making it unnecessary for you to struggle to breath will keep you alive past the time that God wishes for you to live. The idea is to alleviate unnecessary suffering, and especially since it comes from the Church that sees great value in suffering, I would take this direction in a positive way.

What a challenge! Marie, I don’t know on what grounds you surmise I pondered the question of health treatment options more with my next-of-kin than with God. Maybe because you think I reached the “wrong” conclusion? Wrong before God?

How do we make a responsible adult decision on an important personal matter? Surely by bringing into focus both the objective principles and laws which in-form our mind-set and events relating to the question from our personal experience or from circumstances of which we have direct knowledge. This balance is well described in Bishop Geoffrey Robinson’s new book “Confronting Power and Sex in the Catholic Church” publ John Garratt Publishing, Australia.

I had been thinking about these end of life health issues for a couple of years before coming to the conclusion this summer that I must make some formal expression of my preferences, which of course would only come into effect if I were incompetent to make an on-the-spot decision for myself. Even then there would need to be a court decision, backed by a medical opinion of my inability to act for myself, authorising my “attorney” to act in accord with my decision. And yes, I discussed this with my General Practitioner when I saw him in August. Now, in September, the CDF produces this ruling!

Obviously it is possible to scrap my “directive” and you seem to think I ought to. It’s an option that a practising Catholic has to consider, and I have read what I can about the question, including the many comments on the Commonweal blog. But so many comments are based upon personal family experiences, and then the “right” course of action is discerned; no one says “This is the rule – quaestio finita” except in a case where they have no personal involvement.

To opt for a possible course of medication in accord with the CDF response would be contrary to what four separate incidents in my close experience have “taught” me. It would also involve expensive treatment in a situation where health services are strapped for cash. Let alone education. I’ve had my chances- I’ve had my share of the common pot- and why assume that death, my very own death, is a worse option than living?

If you check back through my previous posts on this blog, you will find one on the situation of a young friend with Huntington’s and another on the dire circumstances in the West Bank where I have friends. To my mind this CDF ruling is not Catholic (universal) when the third world is desperate for a clinic or access to a doctor. I’ve been committed throughout my life to frugal living; I’m not going to take the option of the rich now. If I’m wrong, God will sort me out.

Englishwoman

Well, I was afraid that you would take it the wrong way, but I meant that as a sincere question because many people do not take a spiritual view of living and dying. If you read my posts, you'll notice that I do not think the Church is issuing this directive in order to mandate that Catholics follow it, but rather that they have this support from the Church should they feel pressured to end things more quickly than they would like. In a way, any Christian should welcome dying given what they expect is coming next. However, even though one has reservations about using more than one's fair share of resources, it seems presumptuous to say that one is the best judge of what is one's fair share when all that we have is on loan from God.

While the developed world has the resources to provide food, water, and air to sicker people than the third world does, it does not benefit the third world to deprive the citizens of the developed world of the benefits of its medical technology. It seems that the directive as applied in the third world would mandate that one does not cause a person to die of starvation, dehydration, or suffocation, but rather makes whatever effort is required to provide for that person's basic needs for survival. That does not apply only to those afflicted with disease or the elderly. It applies to all those people who die of these things constantly due to mismanagement of resources or war. In other words, this can be extrapolated as making a case against war, for example.

I do not think you should drop your directive for what is to be done should you be incapable of expressing your opinion at that time. Certainly, if you suddenly became disabled in this way, it would be a good representation of your wishes. However, in my opinion people should keep the option open to change such a directive should they find that they have become less sure that they are ready to die when they find themselves in the actual circumstances. And, should they find themselves with this uncertainty, they should not try to convince themselves to go through with it by considering their impact on resources. In my opinion, it is at this end of life time that even those who have had no sense of God's presence in their lives come to notice it and rethink things as a result. It would be a shame to cut that short.

I think anyone should feel what they feel about dying or anything else in life and bring those feelings, as they are, to God in prayer. I don't think feelings can be wrapped in 'shoulds', about dying or anything else. God wants us real before [Him].

Just FYI my friend, I'm with you 100%!

God's peace as always,

e+

The Rev. Dr. E. McCoy

"Has not one God created us? Why then are we faithless to one another, profaning the covenant of our ancestors?" (Malachi 2:10)

Ya know, there is this funny experience on here where people get reminded by others to pray to God. I seem to make the assumption that people are doing that somehow...

I also so clearly remember the day I challenged my pastor on his easy use of that ole catholic/christian cliche about people always being given the strength to handle anything, (which given the horrible things some people actually go through, seems a bit of a cliche, yes?), and he immediately admitted that lameness of that in the face of many situations, and immediately resorted to a story of God teaching someone something after death and another person being made aware of it by the spirit. I'm not "a charismatic" per se, but have experienced the "charismatic moment" and sure can recognize the value of that experience, which is a different response by God than the cliche would suggest....

Jim, I haven't read the document in question. I have read only the NCR report that started this thread.

If the report is accurate, then I don't see such a clear distinction being made in this document between "a person who is dying" and "a person in a persistent vegetative state." I see the document muddling that line.

The key point seems to be me the observation that "the CDF held that even in a situation where there's moral certainty that a patient will never recover, it's not permissible to withdraw food and water, in effect allowing the person to die of dehydration or starvation."

If there's moral certainty that a patient will never recover, then isn't that person dying--even if in a persistent vegetative state?

What moral obligations would then require us to prolong the dying process, given "moral certainty" that the person will never recover? Isn't that what we are actually doing with nutrition and hydration in such cases--not keeping a person alive, but prolonging his or her dying process?

To me, the document adds nothing new to what has been a clear and very useful tradition of Catholic moral thinking about these matters, centered on the distinction between ordinary and extraordinary means. What it does do, though, it seems to me (if the report above is accurate) is muddle the line regarding those who are perhaps brain dead or at the very least in a situation where there's a moral certainty that recovery will never take place.

There's a high price to be paid for that muddling of the line. It imposes guilt on family members who feel responsible to keep a person "alive" at all costs. It implies that by withholding nutrition we are actively killing our loved one, when we are not doing so at all.

I fear that this is another magisterial document that will add to people's burdens, rather than relieving them....And perhaps for reasons that have as much to do with politics as with the gospel....

William D. Lindsey

It seems that this document is a reaction to the Terri Schaivo case where the family held a religious belief that made them desire to shoulder the burden for caring for her. Their standing in the legal case was diminished in relation to the supposed statements the patient had made to her husband in passing conversation because their religion was not clear that it required a certain course of action.

It has been my experience that people often do make statments saying that they would not want this or that in a certain situation, but then when they find themselves in that situation, they have an entirely different perspective. An unconscious person is extremely vulnerable to having opinions attributed to him or her that may not be true or may have changed.

Perhaps, in the Schiavo case, the patient whose soul was still earthbound, but whose body was unable to function properly, would have preferred to be physically present to her family, especially if she was not conscious enough to realize she was suffering or to judge that her quality of life was less than she once judged, and other continue to judge, as minimally tolerable.

The situation here, and in other cases where someone is in a 'persistent vegetative state', has to do with our right to decide that someone's quality of life is not worthy. In a perversion of this well-intentioned sentiment, for example, it might be that people inclined toward social engiineering judge the chronically substance addicted do not have a high enough quality of life.

Nevertheless, I have serious objections to the Church giving exacting instructions as to what to do in any or every particular case, because it deteriorates into what is essentially a version of "Simon Says", where what people do or don't do is based on whether the Vatican says this or that, rather than on their hearing God's voice in the circumstances.

Marie, I think we're coming at this from a very similar angle. Your final paragraph sums up my position, too.

As I see it, part of the problem in the Terri Schiavo case is defining precisely what "family" meant/means in such situations. If I remember aright, her parents and some of her siblings challenged the right of the husband to interpret and convey her unwritten wishes for care in the event she was terminally ill.

The whole event then became a kind of poltico-religious spectacle. My own personal take was to wonder why the same friars and priests and other Catholics who were praying so fervently outside the hospice where Terri Schiavo was dying did not then turn around and head to New Orleans when Katrina hit. People, including children, died there for lack of hydration, too, as we all watched on t.v. and the pro-life government seemed unable or unwilling to get nutrition to them.

I also think there may be a crucial distinction between "persistent vegetative state" and "brain-dead state." If I understood Terri Schiavo's diagnosis correctly, it was the latter.

Though we may perhaps never have absolute certainty that someone is in the latter state and not the former, we can have moral certainty, I think, particularly when expert after expert concludes that this is the state in which a person is existing. I seem to recall that autopsy confirmed the destruction of Terri Schiavo's brain which had been considered the case by all specialists who actually saw her--as opposed to one political leader who "diagnosed" her condition merely by watching a videotape.

These are not easy issues to deal with, admittedly. I have lived through them myself. My mother died of progressive dementia, not having made any determination of her wishes in advance. As her guardian, I had to do that, and had to base my decision on what I had heard her say over the years.

It was a horrible decision to have to make. I would not want to be placed in this position again. I later faced a similar decision with my aunt, who, fortunately, was of sound mine and able to communicate what she wished. Still, at the end, her sister and I had to make concrete decisions about resuscitation, etc.

These are issues we'll all deal with increasingly. People who previously would have died "naturally" can now have their lives (or "lives") prolonged indefinitely, due to technology that allows such prolongation of life--or of the dying process itself.

My hope for the church, in its pastoral life, is to teach clearly, and at the same time, not to increase the pain and suffering of either dying persons or their families.

William D. Lindsey

William,

The Terri Schiavo case, unfortunately for the family, was hijacked by agenda driven people. I think that the circus that this became did more to prevent the husband and his attorney from compromising with the parents and siblings than any specific issues that were under consideration.

I think it is debatable whether the condition of the brain at the autopsy was the result of the dehydration or preexisted it. But, there certainly was no reason to give credence to a doctor-senator's diagnosis from afar. From my perspective it did not really matter what the diagnosis was, since so long as there was someone who was willing to take on the burden of her care, I believe she should have been allowed to live.

I don't agree with you, though, that people can have their lives prolonged indefinitely or that the dying process is prolonged when there are medical interventions for hydration, feeding, and ventilation. Something like this could only be determined if one case could at the same time be given these interventions and not be given these interventions.

Given that any of us make these decisions with the best of intentions, there is no reason to feel guilt over having chosen a path that does not conform in every detail to Church specifications. People come to God all the time before the absolute perfect moment, and God, I presume, has a way of dealing with it. However, I feel it should never be the case that one is prevented from exercising one's best judgment by those whose preference is to hasten death.

Marie, these are exceedingly difficult issues, and are daily being made more difficult, due to the ability of medical technology to prolong life--or, I still maintain, the dying processes--in ways undreamt of previously.

Because of the difficulty of determining what is happening in many cases similar to that of Terri Schiavo, it seems important to me to be very clear with our distinctions.

I am not entirely clear about what you mean in the following paragraph, and would welcome an explanation:

"I don't agree with you, though, that people can have their lives prolonged indefinitely or that the dying process is prolonged when there are medical interventions for hydration, feeding, and ventilation. Something like this could only be determined if one case could at the same time be given these interventions and not be given these interventions."

If your point is to say that we can never have absolute certainty, short of autopsy, about whether someone is in an irreversible medical situation (and is brain dead), then I agree. But to my way of thinking, this does not preclude our making the difficult but morally defensible decision to withdraw nutrition and hydration if we have moral certainty (as opposed to absolute certainty) that the person is brain dead and the situation is irreversible.

In all such decisions, we stand before God. We do so knowing that human knowledge is limited and imperfect, and praying that, given our limited knowledge, we have done the best thing possible under imperfect circumstances.

It's clear to me that we do prolong the dying process in many cases. It's clear to me, as well, that some of the palliatives we administer--e.g., in cases of cancer, when morphine is given--hasten the dying process.

I am at peace with the use of such palliatives, because the end being sought by their administration--easing pain--is not the secondary end that they hasten--i.e., an earlier death.

I have told you of my own involvement with some of these questions, in that I was required to make decisions about my mother's end-of-life care, and to stand by those decisions as she actually died. What I might also add is that my sister-in-law, a very devout Catholic and a woman of deep prayer, is a hospice nurse, and a very gifted one. Much that I keep learning about these issues, I learn from her, since she deals with them on a daily basis.

As an aside, my impression on reading reports re: what Terri Schiavo's autopsy revealed is that it was undubitable that her brain had been destroyed prior to the removal of hydration.

William D. Lindsey

William,

You are right that I am saying that we cannot have absolute certainty. I think all of us who have made decisions on behalf others always have some doubt, and rightly so. This is what makes it so complex that I can at once agree with the directive, but disagree that it should be presented as an absolute requirement.

I think we differ on the issue of brain death. Obviously, a brain that continues to send any kind of signals is not truly dead. However, unless I am mistaken, when people mention brain death, they mean the conscious part of the brain no longer functions.

I understand that the person whose conscious brain no longer functions is no longer the person we knew. However, not everyone thinks in these terms. What I understand from the Catholic Church is that so long as there is any kind of function, the soul is still present in that body, and we do not have the privilege of deciding it is time for it to move on. The idea is that even in such a state, the life of that person may be having an impact on the lives of others that is entirely in conformity with the will of God for those others as well as for the person in question.

In the case of Terri Shaivo, taking the term vegetative to represent what it suggests, one might imagine what the interaction between the husband and the family would have been if she had actually always been, say, a weeping fig tree. They had given the weeping fig to him, he was moving on, and they wanted it back because it was precious to them. Instead of agreeing to that, he insisted that it wished for him to stop watering it. This is the issue as I see it. Her wishes once she was in such a state became irrelevant as compared to the beliefs of the religion she and her family professed.

Since no one can live without air, food, and water, if we can provide them in some way but don't, we are assuring a person's death, which I think is wrong even when that person's life is not what we know they would have wanted it to be. It is the case that people die all the time despite having air, food, and water provided to them. If the body stops making use of these, it dies no matter what we do.

Marie, again, I think that it's important to make some clear distinctions here. The Catholic moral tradition used to have those distinctions, and they were extremely helpful as Catholics approached these anguishing end-of-life situations.

My objection to the latest word from Rome is that it muddles the previous distinctions (I suspect, for political reasons), and will add to the burdens of families facing these anguishing situations.

I understand brain dead to mean dead. That's different from being in a vegetative state, where there's hope of recovery.

As our ability to prolong life has advanced and as medical technology has advanced, our definition of the "moment" of death has had to become ever more refined. There was a time when cessation of breathing was the only measure folks had for when death occurred. That's not a very sophisticated measure, and as a result, people may have been buried alive when it appeared they had died.

The focus then turned to the heart, but we can increasingly revive people whose hearts have stopped. Which turns the focus now to measures of brain activity--and what has happened to the brain--as measures of death.

Again, here's the problem with modern technology: when a person is brain dead, we can prolong that person's "life" indefinitely, though the person is, for all intents and purposes, gone. In the past, these persons (and heart-attack victims, stroke victims, and so on), would have died "naturally."

We are not allowing this natural process of death when we keep a brain-dead person hooked up to machines and feed him/her after brain activity has ceased. The grand irony of much of this is that many religious people say that death should be in the hands of God, and yet appear to be working against God's own activity through nature in prolonging the dying process through technology!

I'm very aware where the anguishing uncertainty lies here: how to determine that a person is truly dead, that the brain has died, that there is no moral certainty of recovery. If there is the whisper of a doubt, I'd be all for prolonging treatment.

But it's rather cruel for us to give hope to people that there may be a recovery, when such hope does not exist. And I also believe it's cruel to the person himself/herself, to maintain that body with nutrition and hydration when the brain is dead.

I don't want such a death for myself.

With the muddying of the lines, we impose burdens on people to try to prolong the "lives" of their loved ones at all cost, even when we may be prolonging the dying process. I've been told by nurses, including my sister-in-law and a nun who was in an ethics class I taught in which this was discussed, that trying to feed and provide water to persons who are actively dying is painful. As the organs shut down, the body naturally rejects the attempt to feed it.

Again, there has been a clear and helpful distinction in classic Catholic moral thinking about these issues that the current documents are over-riding, and in doing so, I fear they will burden people faced with decisions about these matters. This is the distinction between actively killing someone and passively allowing that person's death to proceed.

In making someone who is dying without hope of recovery comfortable, in providing enough water to keep the person from experiencing extreme discomfort, in using palliatives--but in NOT using technology to prolong the dying process--we are not killing someone. We are letting nature take its course.

Rules, regulations, decrees from on high just don't fit the manifold complexity of real human life. When they add burdens to the complex experience of living our human lives in the world today, I don't see them as gospel-oriented.

William D. Lindsey

William,

I don't see us disagreeing at all about the foolishness of this directive. However, I wonder if you might be confusing the freedom Catholics have to decline extraordinary treatment and to issue 'do not recussitate' orders with the former right (now requirement) to insist on life sustaining interventions in cases where someone is identified as being in a vegetative state.

I, personally, do not feel quite so strongly about the feeding as I do about hydration and ventilation, since when people are sick, they often lose their appetites and feeding them under these circumstances amounts to force-feeding. How big an issue this is generally is questionable since it has been my observation that the saline IV is virtually automatic during hospitalizations and that ventilation is readily provided if needed. In my experience, they typically are not disconnected when someone shows evidence of being close to dying--except in one case where I think the decision was made by people who are used to getting absolute guidance and who didn't realize that artificial ventilation would not prevent death.

To me, providing life-sustaining products by artificial means when a body cannot obtain them on its own is no different than continuing to shelter the body from the elements during the time it takes it to die, something we all take for granted will be done even though it involves substantial expense as well. People will die despite having their breathing, feeding, and hydration controlled by machines, but they will not be able to live if their disability makes it impossible to do these things without machines. We disagree to an extent as to whether providing this constitutes prolonging life or whether not providing this constitutes hastening death, because in specific situations it is debatable which approach would cause more physical suffering. As you say, these are complex issues. The Terri Schaivo situation is gives us trouble because prior, more heroic, interventions prevented her natural death and created a situation in which she was severely disabled. Your perception of this seems to suggest that since she was once as good as dead, there was no moral obligation to continue to sustain her. Am I right?

In my opinion, the Schiavo situation was exploited by sincere but overzealous pro-life groups who were in turn exploited by politicians. It is unfortunate that the CDF produced such a case specific document. The function of the Church, often through the CDF, is to offer spiritual guidance. And, considering that the Catholic Church is the one Christian church that teaches that we go on to lead happy and productive afterlives that are not completely disconnected from the physical world, one might expect to find a significant amount of spiritual insight in directives concerning life and death decisions. Instead we have yet another document that seems to indicate that folks at the Vatican watch too much television.

I'm thinking that a person whose decisions are determined by catholic teaching in this area would be very well advised to spend much more time on decisions regarding extraordinary medical care of any kind to begin with, because the teaching is now being changed to make that decision much more of a one way road once someone decides to take it.

Marie, I think we are on the same page here. But your comment on the "four hour death watch" was unclear to me. Did you think the removal of the vent was a bad thing or a good thing? Or are you acknowledging that at the end of life, the walk is hard with or without technology?

I have seen in small ways or large, that when medical technology that is thought to be life sustaining is removed, that rarely does that result in instaneous death. That can cause considerable psychic discomfort to family at the bedside.

Early in my career, I had the acquaintance of a man in his 50's (young) who had had a devastating heart attack (before the miracle of clot busting drugs) and sustaining a very cruel and debilitating stroke on top of his chronic heart failure from a severely damaged heart pump. He went from being a vital and intelligent man to one with a very poor cardiac output and with devastating expressive aphasia. After battling the situation for a year or more, he told his doctor he wanted to go off of all of his meds and die. They studied that situation for a while and eventually he did it. It took him six weeks to die. His doctor remarked on how you think these meds are what keeps people going and then you stop them and it took that long. That couldn't have been easy for anyone to watch the natural course of events as they would have been "without" any meds. Now I'm sure he didn't go off of all of his diuretics and he did have pain and anxiety relief but six weeks is a long time. He stayed the course and probably had much more time than anyone dreamed of to consider the ramifications of his decision. BUt he knew going back on the meds meant living with a terminally damaged heart and brain.

No, still in spite of medical technology, dying is still very, very hard work. We walk the way of the cross, just as Christ did. We walk it with our loved ones who go before us and ultimately, we walk it with ourselves.

MollyJ,

My sense of the situation in which breathing assistance was discontinued is that it was a bad thing, and if it had been my relative, I would not have allowed it. Contributing to my opinion is the fact that my father-in-law died while on a ventilator, despite his being considered on the road to recovery, despite any specific cause, and over a course of hours with us at his bedside--the nurses at the Catholic hospital called us in the middle of the night because they knew that he was dying, because they had seen it so many times before, but they did not disconnect his ventilator despite having been instructed not to recussitate. It seems that to have removed the one thing that was not only keeping the patient that I described alive, but comfortable, was doubly wrong, in fact.

As AnnieO points out above, there is reason to consider starting some of these interventions if the option to discontinue them is not available. It has also been my experience that hospitals and doctors are very hesitant about starting them in the first place already in the case of elderly patients, and I had to insist upon it in the case of my mother, who, like my father-in-law was perfectly able to die without being disconnected from her hydration and feeding tube. I think someone in the medical community would have to prove to me that hydration, food, and air can prevent a person from dying and that depriving someone of water, food, and air is not the same thing as killing him or her.

I understand your position and to be sure, I cannot say that I would have discontinued or not discontinued the vent in a similar situation. One thing I do say, which is a re-phrase of what you said, is "Once you get on the technology train, it is very hard to get off."

And this is a minor point of clarification but I will dive in to it. IV hydration to a greater extent and enteral nutritional feedings do not prevent death. As you said, people DO die on IV's, on vents, with gastric feeding tubes in place. And since no one is running case-controlled interventions on what happens when we do or do not do things like IV's, enteral hyper-al, ventilatory support no can exactly say that these do or do not prolong life. The questions that are more often asked are things like, "Did the cost of this intervention purchase for them a quality extension to their life?". DId the discomfort of the tube justify the intervention? As a former ICU nurse, I can tell you that some folks just couldn't keep their eyes off of the monitor, the technology. They were distracted from being present to the holy experience of dying (and admittedly some folks really want that distraction). They felt unable to embrace their loved one with the ET tube in place. Were we "playing God" to do some of these interventions just to show that we could keep this person alive a little longer?

A last thought that I can leave you with is that at a point in the dying process the body cannot absorb fluids, cannot utilize or absorb nutrients, and the air exchange processes start to break down. The kidneys cannot sift out impurities, off-load extra fluids. Technology pours resources into a vessel that is beyond the need for those resources; it is passing to another time and another dimension.

Obviously for you and many, medical technology and intervention=an expression of caring. And let me assure you that if you put 100 health care professionals in a room and asked them to rank on a continuum questions like, "When is a vent or a g-tube or an IV 'worth it'?" I would expect for them to scatter out among the continuum. These are so obviously questions that are specific to the family and to the patient and to the situation. But I can assure you as a nurse, there is a time when to me those technologies become foul and they can impede the real caring, the simple act of _being with_ someone who is walking their own sacred way of the cross.

I think of you as a thoughtful person and so I'm not trying to disuade you or make you change your mind. As you steward people through the dying process, do what is right for them and for you. But I have tried to give you a little glimpse of why people may choose to do something diametrically different from what you would choose.

I don't disagree with you, but the trend has been toward depriving people of these things when they could benefit from them and desire them. I think this goes back to the confusion caused by the hyperbole that is used to describe advances in medical technology.

The idea that we can prolong life indefinitely is simply wrong. If it were the case, then surely there would be one situation by now in which someone had gone far beyond the normal life expectancy by the use of this technology, if for no other reason than because it would be too great a scientific challenge to ignore.

The reality is that people confuse inventions that are only slightly more complex than a drinking glass or a teaspoon with artificial organ transplants, and decide against them. My position is that people should die from the disease, not from the handicap caused by the disease, and that God is really, directly involved in taking that person and will do so in his time no matter what we do.

Clearly, there are people who are willing to put my belief of God's direct involvement in death to the test who have been deprived of right to do so by those who do not share my religious beliefs and thus make quality of life judgments on behalf of others.

Unfortunately, it has become necessary for the Catholic Church to be very exacting about this in order to protect its members' religious freedom in these situations. Nevertheless, I would have preferred the Church to have articulated a principle rather than to have issued uncompromising requirements.

Marie, I'm going to give you a variety of ideas to chew on.

In my world, I see two extremes. I see people who cannot even get pap smears and elderly demented people having coronary artery bypass surgery. If you broaden your perspective to globally, the disparities are even more acute and just hard to take. Some of the most significant contributers to good health in the United States are things like clean water, sanitation systems, vaccination and prenatal care. In some third world countries those "basic" levels of service are not to be had. I contend that globally we have an obligation to distribute health care in an equitable way. We are talking about apportioning a limited resource, that of health care.

I also want to give you a new perspective on the notion of life span. This link talks about changes in the average life span over time in the United States:
http://www.infoplease.com/ipa/A0005140.html
In 1850, the average life span of a US white male at birth was 38.3 years. For white women, it was 40.5 years. Medicine was pretty rudimentary back then. Don't think there was much in the way of vaccination and no antibiotics. I think Germ theory was evolving. still work was mostly physical and people weren't sedentary.

You could argue that this represents white humans "natural life span" relatively unimpeded by medical intervention.

Flash forward to 2004. In the US, the white male at birth in 2004 has a life expectancy of 75.7; the white female has a life expectancy of 80.8.

This represents a virtual doubling of life expectancy. Many of us contributing at this board represent an absolute anomaly in the calculus of the 1850's. What I am saying is that it is clear that medicine and health care has created impressive strides in life expectancy that are nothing short of miraculous. If you go to the link you will notice that strides were made often during times of war, because war fueled a drive to create more life-saving technologies. I am no expert in the research of geronotology but there is some information that suggests that cells, bodies are programmed to age and wear out. Some work is being done to turn off those biophysiological pathways so that we can enhance life spans further. Not sure why a crowded world needs to do that, personally.

Now I believe that medicine represents utilizing God-given talents to unlock secrets of anatomy, physiology, bacteriology, virology to enchance life and life spans.

I think it is another thing to say that this capacity represents an unlimited good, and we should always seek to extend life, particularly when the quality of life becomes so poor.

Most of us see the enhancements in life expectancy as pure progress. However, progress has a price. And third world constituents DO NOT enjoy a similar advantage.

This web site reports third world countries with lower life expectancy:

http://www.unesco.org/courier/1999_01/uk/dossier/txt21.htm#e1

The 5 countries where life expectancy at birth is lowest for the 2 sexes:
Sierra Leone 38

Malawi 41

Uganda 41

Rwanda 42

Zambia 43

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Source: Yearbook of Labour Statistics, International Labour Office, Geneva, 1997

So the disparities between what different people can get bother me. The mal-distribution of health care over the world bothers me. And then the church comes along and says feeding tubes for all.

I think they are out of touch with a lot of suffering folk in the US and in the world.

And Marie, if you are in the Health Professions, please let me know. And I am agreeing with you that IV's and enteral feedings are pretty common interventions. But I am just going to reflect back to you on this statement:

"The reality is that people confuse inventions that are only slightly more complex than a drinking glass or a teaspoon with artificial organ transplants, and decide against them."

Even ordinary old IV's carry a risk of fluid overload, congestive hear failure, fluid and electrolyte imbalance, sepsis, local infection and plain old suffering. The risks I've listed I have seen and not uncommonly. I don't know how many difficult IV starts you've participated in but needling people isn't that fun for us and it's not my arm. Enteral feeding carries a risk of vomiting, diarrhea, fluid and electrolyte imbalance, aspiration, tube placement into the respiratory tree and discomfort. These are not the highest of the high tech but they are not entirely benign. some people will reasonably say they, "I do not choose this for myself or my loved one."

Finally, one more quote from above:
"My position is that people should die from the disease, not from the handicap caused by the disease, and that God is really, directly involved in taking that person and will do so in his time no matter what we do."

If medicine adhered to this, we would intervene on very little. But it is a fine line of when we in health care operate out of God and when we operate out of our own ego. I realize that I am strictly speaking out of my own experiences and probably only other nurses who have had like experiences may even kind of know what I mean. All I can tell you is that I have seen people saved because the docs knew they could do it but what remained was an enormous burden. and that burden was often borne with love but I've also seen it rend marriages and families, wreck careers and hopes and cause inadvertent neglect of other children in the families. All I am saying is that the act of ego by the doctor or the trauma team or the neonatal team sometimes created a burden of misery that was not subsequently borne by them.

I have always thought that the church's original teaching on health care methods was so loving. In a capsule, I've been told that you were always obligated to care and provide care but if the provision of the care became unduly burdensome it did not have to be continued. I picture that philosophy coming from a gentle parish priest who saw families saying "should i take care of this one or all of them? What should I do, Father?"

I should have read your post before responding to Englishwoman above, because what I wrote to her applies here, particularly the part about the allocation of resources, which I will not repeat here.

I am not advocating the inflexible position that the Church seems to have taken. I am, however, advocating against a position that people sometimes take that is based on medical myth and popular culture. I am not in the medical profession, but I do know many people who are. I am aware that there are instances of health care providers losing sight of the individuals and doing something because it is heroic. On the other hand, once again from a personal perspective, when my husband and I were debating a certain medical procedure and my husband wanted to make his decision based on statistical probabilities, the doctor was quick to point out that the particular individual's circumstances were paramount, not the statistical likelihood.

I know there are risks to be weighed against benefits when deciding how best to deliver the water, food, and air, and I understand that sometimes there will be no benefit given the risks. It is not always necessary to die trying to live; it is possible to put oneself in God's hands exclusively. However, when the risks are not major, but the quality of life judgment is the deciding factor, then I think those making the decision are overstepping their authority, and I think this directive protects Catholics from that exercise of authority, whether from a hospital bureaucracy, a physician's personal preferences, or the government.

MollyJ,

Your wisdom regarding the sacredness of the end stage of life reminded me of my grandmother's situation. She was hospitalized as a result of a stroke after having for a period of time exhibited signs of dementia. She repeatedly removed the tubes that were intended to help her recover. She could not speak English and make her wishes known to the hospital staff, and my father, being the personality he is, would not consider her wishes over his personal religious convictions that it would be murder or suicide to decline medical care. She assaulted the nurses and always somehow found a way to remove the restraints and the tubes. She died after having removed the tubes once again--without any of us present. My father was convinced that the nurses let her die and that his mother had essentially committed suicide. He continues to believe and say that his mother is in hell.

When the Church issues uncompromising directives, the results are two-sided. On the one hand, these serve as legal protection for someone to exercise his or her religious freedom in the face of a legal position that has different priorities. This is similar to its being legally impossible for a Catholic to claim conscientious objector status since Catholicism does not forbid military service; things must be explicitly clear to enable someone to have legal support for a choice based on religious belief. On the other side, people come to believe that if they defy this directive the consequences are extreme. I don't know what is best. Having the state order life support removed from a loved one (or even oneself) against one's preferences is hideous, while one is always free to disregard a Church directive, but people tend to put their faith in what the Church teaches and try to conform themselves without questioning.

Nevertheless, far more significant to this debate is the issue of caring for severly disabled new life. The Church's position, which it supports in deed as well as word, is that there is no disability that justifies withholding the basics that all human life requires--water, air, food. This is seen as totally different from operations to correct a disability, which are not required, but which are likely to find more support from society at large.

As I have stated before, I agree with the Church that delivering water, air, and food without judgment is proper, but I disagree with imposing it on anyone who wishes to decline it. In the case of a new life that cannot choose for itself and that will never be capable of communicating with us, it takes a bit of reflection to understand the virtue in accepting this life as is and taking on the burden, both financial and emotional, of its perpetual care. The virtue is that this burden requires one to build a habit of dialogue with God which is likely to result in something good. One would have to see our lives as being primarily spiritual journeys in order to consider oneself blessed by this burden and view the disabled new life as a gift given by God to help the caregiver in that journey. Despite reflection, whenever I was expecting, I would pray that God would not be this generous to me and so I could never insist that someone take on this burden, but I believe that since the role of the Church is to facilitate and offer direction for the spiritual journey, it has taken the proper position. I do not see it precluding the Church's ability to offer solace to the suffering and dying.