The Papal allocution on caring for persons in a "vegetative state".

• Author: Barry, Robert

ABSTRACT: On March 20, 2004, Pope John Paul II issued a statement to the International Conference on "Life Sustaining Treatments and Vegetative State: Scientific and Ethical Dilemmas" on the provision of food and water to patients in a "vegetative state." The purpose of this allocution was to promote and protect the dignity of patients, even when they are in a seriously ill and disabled state. To promote the dignity of these patients, the Pope explicitly stated that "quality of life judgments" were not to be applied to the administration of nutrition and fluids. The Holy Father made it clear that he was avoiding any position that could be construed as tolerating, permitting, or promoting euthanasia by omission. His statement sought to prevent Catholics and Catholic health care facilities from becoming involved in euthanasia by omission that has become a fast-growing threat.

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On March 20, 2004, Pope John Paul II issued a statement to the International Conference on "Life Sustaining Treatments and Vegetative State: Scientific and Ethical Dilemmas" on the provision of food and water to patients in a "vegetative state." In the past 25 years, there has been a great deal of controversy about the level of awareness of those in this state, their ability to experience pain, and their cognitive capabilities. There has also been extraordinary controversy about the moral requirements to treat and sustain individuals in this state. At this conference, it became clear that contemporary medicine knew very little of the abilities, experiences and cognitive abilities of those in this state, and a number of speakers made it clear that it is not at all certain that patients in coma, persistent unconsciousness or "vegetative state" are beyond thought, pain or experience of the external stimuli. It is because of this uncertainty about their condition that Pope John Paul II issued this statement. In it, he wanted to give every moral protection to patients in a "vegetative state" and give no moral justification to those who would end their lives by an act of deliberate omission. In his statement, the Holy Father declared that the provision of artificial nutrition and hydration was not a medical treatment, but was "basic" or "normal care" and that there was a "moral obligation" to provide it to the persistently unconscious. (1) He denied that tube feeding could be administered to patients according to the traditional standards of "ordinary and extraordinary" care and treatment and called these measures "basic health care," and a "natural means of preserving life." (2) Many ask why this statement was not issued earlier, and I believe the reason for that was that he wanted to give medicine and science more time to learn more about the nature of persistent unconsciousness. But when it became clear that this condition remained mysterious and ill-understood, he decided to speak out to protect the victims of this condition.

The purpose of this allocution was to promote and protect the dignity of patients, even when they are in a seriously ill and disabled state. (3) He protested that the use of the term "vegetative state" for the persistently unconscious was a demeaning term and did not show proper respect for their human dignity. He was correct in pointing out that this term did not identify any independent medical condition, but was merely a term used to describe a person who had been unresponsive for a year or more. (4) Despite his protest, this term endures rather than more respectful terms such as "persistent unconsciousness" or "persistent coma."

To promote the dignity of these patients, the Pope explicitly stated that "quality of life judgments" were not to be applied to the administration of nutrition and fluids. (5) The Holy Father was particularly critical of those who would justify withdrawal or withholding food and water from these patients because they possess an insufficient "quality of life." This criticism was aimed at those who justify withdrawing medical treatments or withholding food and water from them for "quality of life" reasons. These judgments might be suitable for a secular ethics, but they are not a genuine aspect of Catholic medical ethics because they deny the infirm, disabled and handicapped individuals care and treatments that can be of benefit to them. (6) Included in this category of "quality of life" judgments is the belief that those in a vegetative state have lost their "spiritual and affective" potentiality and can no longer operate toward spiritual and affective goals. In this view, patients in a vegetative state can receive no significant benefit from being fed and hydrated, and the Holy Father implied that this type of judgment was as prejudicial against persons with disabilities as are quality of life judgments. The Holy Father made it clear in his statement that he was being very careful to avoid any position that could be construed as tolerating, permitting or promoting euthanasia by omission. (7) He defined the provision of food and water, even with feeding tubes, as "a natural means" of sustaining life and not as a "medical act" because he wanted to guarantee that there would be no gap in the provision of feeding and hydration as patients descend into unconsciousness. He chose to run the risk of providing food and water that the patient might not be able to ingest rather than risk denying these vulnerable patients a "cup of water and a morsel of bread."

The Papal allocution came as a surprise to many, but such a statement is not without precedent. When confronted with the emergence of successful organ transplants from live donors, Pope Pius XII faced objections from Catholic ethicists that removing an organ from a donor was a mutilating procedure done on the donor for non-therapeutic purposes by invoking a principle first established by Aquinas. (8) Plus claimed that this "mutilation" was justified because it was a life-saving act of charity. Even further, in the days when morphine was first being used to control pain and it was difficult to control its side-effects, he also declared that it was legitimate to use pain relievers in such doses that they would increase the risk of death if this was done from the primary intention of alleviating pain...