2016-07-27
Excerpted from the Revised (1999) Edition of "Nutrition and Hydration: Moral Considerations: A Statement of the Catholic Bishops of Pennsylvania." Click here for the full text.

Recent court decisions and the enactment of federal and state laws governing advance medical directives (living will or durable power of attorney) have given many the impression that anything the courts or the civil laws allow is morally acceptable. The issue of the withholding or withdrawal of nutrition and hydration in particular has become controverted. ... ... Modern medicine continues to deal with age-old questions, even though current knowledge and technologies offer treatments and procedures that would once have been impossible. One such area is the supplying of nutrition and hydration to patients who are incapable of feeding themselves and are unable to take nourishment orally even with assistance. It is now possible to sustain the lives of such patients with a variety of techniques, and so arises the question of the moral obligation to do so. ... ... All states of unconsciousness are often referred to (even by medical personnel) as "coma." This is, in fact, not a correct designation.(10) Coma is but one type of impaired consciousness. There are also others which we should consider because all of them present situations in which problems may arise in terms of the supplying of nutrition and hydration.
A true coma is a state of "unarousable unresponsiveness" with no response to external stimuli. The person is not dead, but is in a state of sleep. This condition is never permanent.(11) It may last as long as six months, but it will resolve itself into some other state. The person may emerge into consciousness again or sink into another state, such as that which is referred to as the persistent vegetative state. It may take some time, even months, to diagnose the exact condition. The persistent vegetative state (PVS) is deeper than a coma. The coma is a state of sleep; PVS is a form of deep unconsciousness. The cerebrum, the upper part of the brain, gives evidence of impaired or failed operation - and it is this portion of the brain, in its cortex or outer layer, which is responsible for those activities that we recognize as specifically human.(12) Another portion of the brain, the brainstem, is, however, still functioning in the PVS patient. It is this portion of the brain which controls involuntary functions such as breathing, blinking, involuntary contractions, and cycles of waking and sleep. Thus PVS patients may open their eyes and sometimes follow movement with them or respond to loud and sudden noises (although these responses will be neither long sustained nor apparently purposeful). There will be cyclical stages of sleeping and waking, but such activity is a function of the brainstem and is not an indicator of purposeful human activity."(13) PVS is sometimes referred to as "cerebral death." This is an unfortunate terminology, since it seems to imply that there is "brain death" as described earlier. This is not true. There is a failure of function at one level in the brain, but not all, and the person in PVS is definitely not dead. Even medical personnel sometimes refer to such a patient as "brain dead." This is simply not the case.(14)
There is also a state which is referred to as psychiatric pseudocoma. This is a state of unconsciousness caused by shock or trauma which lead the victim to close off from the outside world. This may be so severe as to give the appearance of death, but it is not even truly a state of unconsciousness. It is simply total lack of response. Finally, there is another condition which is referred to as the locked-in state. This condition is caused by an interruption in the descending motor pathways of the nervous system. In this condition, paralysis, not cognitive failure, leads to a lack of ability to communicate."(15) The patient is fully conscious, but simply has no way in which to indicate conscious response. (In some cases, however, depending on where the motor pathways are interrupted, communication may be possible by such means as coded eye blinking.) It takes careful diagnosis not to mistake this patient for the PVS patient. PET scans can distinguish between the locked-in state and the persistent vegetative state. The EEG, however, cannot do so, since the patient in the locked-in state may show an abnormal response, while the PVS patient may produce readings that are near-normal.(16) Patients who have recovered from this condition reveal that they were indeed conscious and well aware of what was going on around them - and had a strong desire to continue to live. In none of these classes of unconscious patients are we dealing with the dead. All of them are alive and some of them may well be expected to recover. The one case in which recovery becomes most unlikely is that of the PVS patient, and it is this patient who is likely to become the object of decision making in regard to continued treatment or care, or supplying of nourishment.
ORDINARY AND EXTRAORDINARY MEANS OF CARE(17) The Catholic moral tradition holds that one is morally obliged to use the ordinary means of sustaining life, but is not obliged to make use of extraordinary means."(18) Ordinary means are those which are available and do not require effort, suffering or expense beyond that which most people would consider appropriate in a serious situation. This would include most of the developed procedures and techniques commonly practiced in medicine and surgery. However, moralists recognize that there are also subjective elements which influence our ability to make moral judgments. Subjective considerations of pain, expense and personal abhorrence may act as obstacles to the fulfillment of this obligation. Furthermore, not all techniques have to be used in every instance. What would usually be ordinary means may, in certain cases, offer little hope of success and may prove more burdensome than beneficial to the user. In such situations one would not be morally obliged to use such means.(19) The distinction between ordinary means (which we are morally obliged to use) and extraordinary means (which we may choose to use, but are not obliged to) is not based solely on the commonness and availability of the means themselves, although this is taken into account. It is also based on the results that one can expect and on certain serious subjective considerations and attitudes as well. It takes into account the proportion between benefit and burden. ... Feeding Methods

There are various ways to supply nourishment to the unconscious. The general categories would include at least these three: Oral feeding, enteral feeding and parenteral feeding. Oral feeding simply means that food (which may be pureed) or drink can be placed in the mouth and the patient will then swallow it. For some patients, even in the persistent vegetative state, this may be enough, provided that the swallowing reflex is sufficiently unimpaired. At times, however, the medical staff will prefer not to use this method, even in cases where it could be used, since it can be quite time consuming for a staff that may already have a large number of patients to care for.(24)

Enteral (within the bowel) feeding means that the nourishment is placed directly into the upper end of the small intestine. This can be accomplished by means of a nasogastric (through the nose and into the stomach) or nasoduodenal (through the nose and into the upper end of the small bowel) tube, or it can also be done through a gastrostomy ( an opening directly into the stomach) or jejunostomy (an opening into the upper part of the small bowel). This method does not usually result in complications and, even if some complications do arise, they are usually not of a serious nature(25), but the method does presuppose that the gastrointestinal tract is intact and functioning.

Parenteral (outside the bowel) feeding refers to the supplying of nourishment intravenously. This may be done when the gastrointestinal tract is not intact or does not function. It may be accomplished for a short time by means of tubes inserted into the peripheral veins (e.g., in the arms or legs), but this can easily lead to thrombosis (clotting). Therefore, if it is to be used for longer periods, it is done by inserting a tube into the central venous system.(26) There is need for daily monitoring of nutrients, waste products and blood chemistry until the patient becomes stable, after which monitoring can be less frequent. This method of nutrition also carries with it greater risks of complications. Metabolic complications may arise, resulting in bone disease, liver dysfunction or other problems. There may also be nonmetabolic complications, such as thrombosis or the introduction of infecting organisms. However, the relative simplicity of this method is evidenced by the fact that in some situations it has been used as a form of home care allowing some types of conscious patients to resume many of their normal activities. Decisions in Relation to Nutrition and Hydration There are instances in which it is relatively easy to apply moral principles to the decision to withhold or withdraw nutrition. In the case of a terminal cancer patient whose death is imminent, for instance, the decision to begin intravenous feeding or feeding by nasogastric tube or gastrostomy, may also mean that the patient is going to endure greater suffering for a somewhat longer period of time - without hope of recovery or even appreciable lengthening of life. Weighing the balance of benefits versus burdens makes it relatively easy to decide that this could fall into the category of extraordinary means and that such feeding procedures need not be initiated or may be discontinued.
We are faced with a different set of questions when we begin to examine the case of the long-term patient who must be fed by some of the means described above (i.e., those more complicated than assisted oral feeding). The question of patients in the persistent vegetative state is particularly important. There is no question here of "brain death, " even though that term is so frequently misused in the media (who cannot always be expected to know better) and by medical practitioners (who certainly ought to know better). The PVS patient is alive, but unconscious and, therefore, unable to take nourishment without assistance. It is clearly not a question of deciding to stop treatment because the patient has died. Questions relative to the supplying of nutrition and hydration are often qualified by the term "artificial." The discussion thus tends to center on whether artificial nutrition and hydration are to be continued or not in certain cases. It is not, however, the question of whether a type of care is artificial or natural that makes the difference in terms of its continuance or discontinuance. The fact is that every mode of taking in food and drink is, to some extent, artificial. This is the case whether we speak of the patient receiving parenteral feeding or the honored guest at a banquet for royalty - a banquet which observes every nicety of the most sophisticated table manners and requires a certain expertise in the recognition of all appropriate cutlery. Both situations provide nourishment and both also use some artificial means to supply it. The real question, when it comes to decision making for the unconscious patient, depends in the final analysis on something other than a distinction between artificial and natural means. If the supplying of nutrition and hydration is of benefit to the patient and causes no undue burden of pain or suffering or excessive expenditure of resources, then it is our duty to take and to provide that nutrition and hydration. If the burdens have far surpassed the benefits, then our obligation has ceased.
A distinction is also often made between treatment and care. In the case of the patient in the persistent vegetative state, some would hold that we are obliged to continue to supply the proper care, but are not obliged to continue treatment.(27) The reason for this statement is that treatment in this instance is no longer useful in resolving the unconscious state of the patient. For many, then, it becomes a question of whether feeding constitutes treatment or care. If the former, then it may be discontinued. If the latter, it must continue. Statements by the Pontifical Council on Health Affairs and the Pontifical Academy of Sciences both hold to this distinction and say that treatment may be discontinued, but they then go on to explain that they view the supplying of nutrition and hydration as care - which must, therefore, be continued (presupposing, of course, the distinctions already made in reference to the question of excessive burdens).(28) There is, however, another way to look at this. In the case of the imminently terminal patient one would suppose that treatment is intended to reverse the course of the disease or, at least, to better the condition of the patient. If it no longer does that, then its discontinuance is no more than a clear recognition of its futility. Even feeding methods other than oral thus become futile and can be stopped so as to attend more to the comfort of the one who is dying. In certain clearly defined cases, then, even certain types of care might become extraordinary if they were futile or excessively burdensome.
However, the patient in the persistent vegetative state is not imminently terminal (provided that there is no other pathology present). The feeding - regardless of whether it be considered as treatment or as care - is serving a life-sustaining purpose. Therefore, it remains an ordinary means of sustaining life and should be continued. In other words, the mere distinction between treatment and care does not of itself resolve the moral problem. Rather, its resolution still remains within the scope of the usual norms of ordinary and extraordinary means. Whether it is viewed as treatment or care, it would be morally wrong to discontinue nutrition and hydration when they are within the realm of ordinary means. ... CONCLUSION

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, but those are the exceptions and should not be made into the rule. We can and do offer our sympathy and support to those who must make such hard decisions in those difficult cases. We cannot and do not offer our support to those who are willing to remove from patients the means of sustaining nourishment on the ground that their lives are not worthy of our continued care and concern.

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