Catholic Decree on Comatose Patients

On Sunday, January 3rd, the San Francisco Chronicle published an article entitled "Catholic decree on comatose patients." The writer relied heavily on the website opinions of Barbara Coombs Lee, president of Compassion & Choices, a leading advocate of euthanasia and physician-assisted suicide. The Chronicle article and the Lee blogs have received a good deal of national attention.

These writers are addressing the 2009 revisions to Part Five and Directive 58 of the Ethical and Religious Directives for Catholic Health Care Services (ERDs). The last revision of these Directives was made in 2001. At that time, the Vatican had not addressed the morality of providing medically-assisted nutrition and hydration (MANH) to patients in a vegetative state (PVS).

John Paul II and the Congregation for the Doctrine of the Faith (CDF) addressed this question in 2004 and 2007. The American bishops revised Part Five of the Directives to bring them into sync with these official statements from the Holy See.

The Chronicle article and the Lee opinions name these revisions "a new religious mandate" and "the bishops' order," and gravely misrepresent the revised teaching. They claim that the revisions will inflict "duress and shame on the "very vulnerable" in hospitals and nursing homes. These writers also falsely claim that from now on a Catholic health care facility will not honor a patient's Advance Directive regarding MANH.

Due to erroneous reports such as these, a good amount of confusion has been created about the Catholic church's stance on MANH and Advance Directives. It is necessary, then, to carefully and accurately explain the revisions in the ERDs.

The Catholic moral tradition strongly believes in the intrinsic and fundamental dignity of every human person. Contrary to other opinions, the Catholic tradition maintains that persons never lose their human dignity no matter what physical or psychological difficulties they may experience. Some argue that persons forfeit human dignity, e.g., when they no longer are conscious, are unable to communicate, or are no longer capable of recognizing others. This point of view is often referred to as "accrued dignity" and stands in direct opposition to Catholic understanding of fundamental, intrinsic and lasting dignity.

In a 2004 allocution, John Paul II spotlighted PVS patients. Because they never lose their basic human dignity, they must "in principle" be supplied with MANH unless there are clear counter-indications, e.g, the person is dying, MANH will have no benefit, or MANH cannot accomplish its finality to nourish the patient. This is why John Paul II named MANH a natural means of preserving life and as a general rule ordinary and morally obligatory. In 2007, the CDF reaffirmed this papal teaching and offered a number of important clarifications.

The words "in principle" and "as a general rule" clearly indicate that patients who cannot take food and water by mouth do not have to receive MANH. The revisions are not intended, therefore, to replace the reasoned decision of patients, surrogates, and their physicians.

What precisely do the revisions teach?

• Persons never lose their fundamental human dignity.
• There is a general obligation to provide patients with water and food, including MANH.
• This obligation ceases or becomes morally optional when the measures taken do not reasonably prolong a person's life and when the measures become excessively burdensome, e.g., cause chronic diarrhea, create consistent physical discomfort such as lesions and bruising.
• A distinction needs to be made between patients in a chronic state, e.g., quadriplegia, mental illness, Alzheimer's disease, PVS patients, and those who are dying.

Since the 16th century, the Catholic tradition has made the distinction between ordinary/proportionate and extraordinary/disproportionate means of health care. In the 1950s, Pope Pius XII utilized this distinction by teaching that a patient might sustain a "moral impossibility" regarding a certain type of medical care/procedure. This "impossibility" might lead a patient to make a judgment in conscience that a specific type of care is extraordinary or disproportionate.

The Catholic tradition has established five criteria that might lead a patient to experience "moral impossibility." (1) Great effort, e.g., move to another location more amenable to one's health. (2) Enormous pain, e.g., amputation. (3) Exquisite means, e.g., eating specialized foods. (4) Extraordinary expense, e.g., beyond one's (or one's family) ability to pay. (5) Severe dread, e.g. personal horror regarding a particular medical treatment.

Directives 28 and 59 of the ERDs support a competent adult (patient or surrogate) to make informed decisions about one's care, expressed, e.g., in an Advance Directive. Both of these directives point out that these decisions should always be respected "unless [they] are contrary to Catholic moral teaching."

Directive 60 spells out what this means. Catholic health care institutions may never condone or participate in euthanasia or assisted suicide, and patients must be permitted to live "with dignity" until the time of natural death. Would a Catholic hospital honor a person's Advance Directive which indicates personal severe dread and horror at being fed by tubes. Yes.

Would a Catholic hospital honor a person's Advance Directive which indicates the request to die, e.g., if diagnosed in a PVS condition, because "I am no longer a human being, having lost certain functions of the upper brain." This statement amounts to an appeal for euthanasia and a belief that PVS patients no longer have fundamental human dignity.

For the sake of a person's pastoral and moral welfare, it is important to have a correct understanding of the recent revisions to the ERDs and not be mislead by erroneous and misleading opinions.

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