The Common Good
August 2004

End-of-Life Ethics

by Julie Polter | August 2004

What is 'artificial means' and what is nonnegotiable humane care?

As anyone who has undergone major surgery might attest,

As anyone who has undergone major surgery might attest, medical technology available to keep the human body functioning through trauma, treatment, and healing - means that we often take for granted today - would have been viewed as little short of a miracle even a few decades ago.

But many of us also assert that we would not want to be "kept alive by tubes" if we were in the final days of a terminal illness or considered to be in a deep state of unconsciousness with no hope of recovery. A "living will" - a written declaration of the treatment one does or does not want to receive if circumstances leave one unable to communicate - is one way to make this desire known. In the absence of such an advance directive, the treatment decisions fall to the patient's next of kin.

What, however, is "treatment" and what is simply nonnegotiable, humane care? This spring Pope John Paul II, at a meeting focused on care of patients in a vegetative state, declared that "the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act," and is, as such, "morally obligatory."

These statements run counter to the teachings of many Catholic ethicists and current U.S. legal interpretation. The U.S. Supreme Court ruled in 1990 that feeding tubes that deliver nutrition and hydration to a person in a vegetative state are a medical treatment that can be withdrawn if there is "clear and convincing" evidence that the person would not want his or her life prolonged under such conditions.

Since 1992, the U.S. Catholic bishops have encouraged the continued feeding of patients in a "persistent vegetative state," or PVS, but reserved the final decision for families and doctors. (A "persistent vegetative state" means that a person has lost cognitive functions and awareness, while retaining non-cognitive functions such as breathing, normal sleep patterns, and sometimes reflexive responses to certain stimuli.)

For the time being, Catholic hospitals (more than 11 percent of the nation's total community hospitals) will continue their current policy of honoring living wills and the requests of next of kin except in the case of requests that staff determine to be illegal or immoral due to specific circumstances. Meanwhile, moral theologians and medical ethicists are examining the long-term implications of the pope's pronouncements for Catholic-provided healthcare.

THIS CONTROVERSY provides an opportunity for reflection for all Christians, Catholic and otherwise. The decisions to be made in the case of apparent PVS are rarely simple. The determination of whether someone is in a persistent vegetative state is not an exact science - a British study in the mid 1990s found that 43 percent of a group of patients diagnosed as PVS (17 out of 40 studied) were misdiagnosed (later found to be alert and able to communicate). And given the flawed nature of human beings, family members charged with making care decisions for an incapacitated patient may not always have the patient's best interests at heart.

Christian tradition calls us to give special care and attention to the weakest in our community, and to view life as sacred in a way that is not diminished by illness or disability. On the other hand, most Christians believe that the everyday miracle that is our body is not the sum total of our existence. Death, the inevitable surrender of the physical being, is in another way just a step in the life of faith.

All of this is a reminder that, as difficult as the topic may be, we owe it to ourselves and the people who we love to discuss end-of-life issues in our families and with our pastors. Living wills and other forms of advanced directives are not perfect (and are useless if your healthcare provider doesn't know that you have one - a common occurrence). But they are the best vehicle for making your wishes known at a time when you are unable to communicate them, and may make a difficult time somewhat easier for those you love.

Julie Polter is an associate editor of Sojourners.

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