Nutrition and hydration: moral and pastoral reflections.

• Position: Report of the Committee for Pro-Life Activities, National Conference of Catholic Bishops, April 1992

Committee for Pro-Life Activities

National Conference of Catholic Bishops

April 1992

Introduction

Modern medical technology seems to confront us with many questions not faced even a decade ago. Corresponding changes in medical practice have benefited many, but have also prompted fears by some that they will be aggressively treated against their will or denied the kind of care that is their due as human persons with inherent dignity. Current debates about life-sustaining treatment suggest that our societys' moral reflection is having difficulty keeping pace with its technological progress.

A religious view of life has an important contribution to make to these modern debates. Our Catholic tradition has developed a rich body of thought on these questions, which affirms a duty to preserve human life but recognizes limits to that duty.

Our first goal in making this statement is to reaffirm some basic principles of our moral tradition, to assist Catholics and others in making treatment decisions in accord with respect for God's gift of life.

These principles do not provide clear and final answers to all moral questions that arise as individuals make difficult decisions. Catholic theologians may differ on how best to apply moral principles to some questions not explicitly resolved by the Church's teaching authority. Likewise, we understand that those who must make serious health care decisions for themselves or for others face a complexity of issues, circumstances, thoughts, and emotions in each unique case.

This is the case with some questions involving the medically assisted provision of nutrition and hydration to helpless patients--those who are seriously ill, disabled, or persistently unconscious. These questions have been made more urgent by widely publicized court cases and the public debate to which they have given rise.

Our second purpose in issuing this statement, then, is to provide some clarification of the moral issues involved in decisions about medically assisted nutrition and hydration. We are fully aware that such guidance is not necessarily final because there are many unresolved medical and ethical questions related to these issues, and the continuing development of medical technology will necessitate ongoing reflection. But these decisions already confront patients, families, and health care personnel every day. They arise whenever competent patients make decisions about medically assisted nutrition and hydration for their own present situation, when they consider signing an advance directive such as a "living will" or health care proxy document, and when families or other proxy decisionmakers make decisions about those entrusted to their care. We offer guidance to those who, facing these issues, might be confused by opinions that at times threaten to deny the inherent dignity of human life. We therefore address our reflections first to those who share our Judeo-Christian traditions, and secondly to others concerned about the dignity and value of human life who seek guidance in making their own moral decisions.

Moral Principles

The Judeo-Christian moral tradition celebrates life as the gift of a loving God and respects the life of each human being because each is made in the image and likeness of God. As Christians we also believe we are redeemed by Christ and called to share eternal life with Him. From these roots the Catholic tradition has developed a distinctive approach to fostering and sustaining human life. Our Church views life as a sacred trust, a gift over which we are given stewardship and not absolute dominion. The Church thus opposes all direct attacks on innocent life. As conscientious stewards we have a duty to preserve life while recognizing certain limits to that duty:

1. Because human life is the foundation for all other human goods, it has a special value and significance. Life is "the first right of the human person" and "the condition of all the others."

2. All crimes against life, including "euthanasia or willful suicide," must be opposed. Euthanasia is "an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated." Its terms of reference are to be found "in the intention of the will and in the methods used." Thus defined, euthanasia is an attack on life which no one has a right to make or request, and which no government or other human authority can legitimately recommend or permit. Although individual guilt may be reduced or absent because of suffering or emotional factors that cloud the conscience, this does not change the objective wrongfulness of the act. It should also be recognized that an apparent plea for death may really be a plea for help and love.

3. Suffering is a fact of human life and has special significance for the Christian as an opportunity to share in Christ's redemptive suffering. Nevertheless there is nothing wrong in trying to relieve someone's suffering; in fact it is a positive good to do so, as long as one does not intentionally cause death or interfere with other moral and religious duties.(4)

4. Everyone has the duty to care for his or her own life and health and to seek necessary medical care from others, but this does not mean that all possible remedies must be used in all circumstances. One is not obliged to use either "extraordinary" means or "disproportionate" means of preserving life-that is, means which are understood as offering no reasonable hope of benefit or as involving excessive burdens. Decisions regarding such means are complex and should ordinarily be made by the patient in consultation with his or her family, chaplain or pastor, and physician when that is possible.

5. In the final stage of dying one is not obliged to prolong the life of a patient by every possible means: "When inevitable death is imminent in spite of the means used, it is permitted in conscience to take the decision to 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."

6. While affirming life as a gift of God, the Church recognizes that death is unavoidable and that it can open the door to eternal life. Thus, "without in any way hastening the hour of death," the dying person should accept its reality and prepare for it emotionally and spiritually.

7. Decisions regarding human life must respect the demands of justice, viewing each human being as our neighbor and avoiding all discrimination based on age or dependency.(8) A human being has "a unique dignity and an independent value, from the moment of conception and in every stage of development, whatever his or her physical condition." In particular, "the disabled person (whether the disability be the result of a congenital handicap, chronic illness, or accident, or from mental or physical deficiency, and whatever the severity of the disability) is a fully human subject, with the corresponding innate, sacred, and inviolable fights." First among these is "the fundamental and inalienable right to life."(9)

8. The dignity and value of the human person, which lie at the foundation of the Church's teaching on the right to life, also provide a basis for any just social order. Not only to become more Christian, but to become more truly human, society should protect the right to life through its laws and other policies.(10)

   While these principles grow out of a specific religious tradition, they appeal to a common respect for the dignity of the human person. We commend them to all people of good will.

   Questions about Medically Assisted Nutrition and Hydration

   In what follows we apply these well-established moral principles to the difficult issue of providing medically assisted nutrition and hydration to persons who are seriously ill, disabled, or persistently unconscious. We recognize the complexity involved in applying these principles to individual cases and acknowledge that, at this time and on this particular issue, our applications do not have the same authority as the principles themselves.

1. Is the Withholding or Withdrawing of Medically Assisted Nutrition and Hydration Always a Direct Killing?

   In answering this question one should avoid two extremes.

   First, it is wrong to say that this could not be a matter of killing simply because it involves an omission rather than a positive action. In fact a deliberate omission may be an effective and certain way to kill, especially to kill someone weakened by illness. Catholic teaching condemns as euthanasia "an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated." Thus "euthanasia includes not only active mercy killing but also the omission of treatment when the purpose of the omission is to kill the patient."

   Second, we should not assume that all or most decisions to withhold or withdraw medically assisted nutrition and hydration are attempts to cause death. To be sure, any patient will die if all nutrition and...