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Notes

1. Congregation for the Doctrine of the Faith, Declaration on Procured Abortion (1974), no. 11.

2. Second Vatican Council, Gaudium et spes, no. 27. Suicide must be distinguished from "that sacrifice of one's life whereby for a higher cause, such as God's glory, the salvation of souls or the service of one's brethren, a person offers his or her own life or puts it in danger." Congregation for the Doctrine of the Faith, Declaration on Euthanasia (1980), Part I.

3. Declaration on Euthanasia, Part II.

4. See: Declaration on Euthanasia, Part III; United States Catholic Conference, Ethical and Religious Directives for Catholic Health Facilities (1971), Directive 29.

5. Declaration on Euthanasia, Part IV.

6. Ibid.

7. Ibid, Conclusion.

8. Gaudium et spes, no. 27; Declaration on Procured Abortion, no. 12.

9. Document of the Holy See for the International Year of Disabled Persons (March 4, 1981), 1.1,11.1: Origins, Vol. 10 (1981), pp. 747-8.

10. Declaration on Euthanasia, Introduction; Declaration on Procured Abortion, nos. 10-11, 21; Sacred Congregation for the Doctrine of the Faith, Instruction on Respect for Human Life in Its Origin (1987), Part III.

11. Archbishop John Roach, "Life-support removal: No easy answers," Catholic Bulletin, March 7, 1991, p. 1 (citing Bio/medical Ethics Commission of the Archdiocese of St. Paul-Minneapolis).

12. "If all fluids and nutrition are withdrawn from any patient, regardless of the condition, he or she will die -inevitably and invariably. Death may come in a few days or take up to two weeks. Rarely in medicine is an earlier death for the patient so certain." Ronald E. Cranford, M.D., "Patients with Permanent Loss of Consciousness," Joanne Lynn (ed.), By No Extraordinary Means (Indiana University Press 1986), p. 191.

13. See the arguments made by a judge in the Elizabeth Bouvia case and by the attorneys in the Hector Rodas case, among others. See Bouvia v. Superior Court, 225 Cal. Rptr. 297, 307-8 (1986) (Compton, J., concurring); Complaint for the Declaratory Relief in Rodas Case, Issues in Law and Medicine, Vol. 2 (1987), pp. 499-501, quoted verbatim from Rodas v. Erkenbraclç No. 87 cv 142 (Mesa County, Cob., filed Jan. 30, 1987).

14. As one medical ethicist observes, interest in a broadly permissive policy for removing nutrition and hydration has grown "because a denial of nutrition may in a long run become the only effective way to make certain that a large number of biologically tenacious patients actually die." Daniel Callahan, "On Feeding the Dying," Hastings Center Report, Vol. 13 (October 1983), p. 22.

15. See text: MORAL PRINCIPLES, no. 5.

16. Address to a Human Pre-Leukaemia Conference, November 15, 1985: AAS, Vol. 78 (1986), p. 361. Also see his October 21, 1985 address to a study group of the Pontifical Academy of Sciences: "Even when the sick are incurable, they are never untreatable; whatever their condition, appropriate care should be provided for rhem." AAS, Vol. 78 (1986), p. 314; Origins, Vol. 15 (December 5, 1985), p. 416.

17. Some groups advising the Holy See have ventured opinions on this point, but these do not have the force of official church teaching. For example, in 1985 a study group of the Pontifical Academy of Sciences concluded: "If a patient is in a permanent, irreversible coma, as far as can be foreseen, treatment is not required, but all care should be lavished on him, including feeding." Pontifical Academy of Sciences, "The Artificial Prolongation of Life," Origins, Vol. 15 (December 5, 1985), p. 415. Since comatose patients cannot generally take food orally, the statement evidently refers to medically assisted feeding. Similar statements are found in : Pontifical Council Cor Unum, Question of Ethics Regarding the Fatally Ill and the Dying (1981), p. 9; "Ne Eutanasia Ne Accanimento Terapeutico," La Civilta Cattolica, Vol. 3280 (February 21, 1987), p. 324.

18. World Medical Association, Declaration of Helsinki (1975), 11.1.

19. See Joyce V. Zerwekh, "The Dehydration Question," Nursing (January 1983), pp. 47-51.

20. See William E. May et al., "Feeding and Hydrating the Permanently Unconscious and Other Vulnerable Persons," Issues in Law and Medicine, Vol. 3 (Winter 1987), p. 208.

21. Ronald E. Cranford, "The Persistent Vegetative State: The Medical Reality (Getting the Facts Straight)," Hastings Center Report Vol. 18 (February/March 1988), p. 31.

22. Declaration on Euthanasia, Part IV (emphasis added).

23. Current ethical guidelines for nurses, while generally defending patient autonomy, reflect this concern: "Obligations to prevent harm and bring benefit. . require that nurses seek to understand the patient's reasons for refusal. . . . Nurses should make every effort to correct inaccurate views, to modify superficially held beliefs and overly dramatic gestures, and to restore hope where there is reason to hope." American Nurses' Association Committee on Ethics, "Guidelines on Withdrawing or Withholding Food and Fluid," BioLaw, Vol. 2 (October 1988), pp. U 1124-5.

24. In one such study, "seventy percent of patients and families were 100% willing to undergo intensive care again to achieve even one month of survival"; "age, severity of critical illness, length of stay, and charges for intensive care did not influence willingness to undergo intensive care." Danis et al., ~Patients' and Families' Preferences for Medical Intensive Care," Journal of the American Medical Association, Vol. 260 (August 12, 1988), p. 797. In another study, out of 33 people who had close relatives in a "persistent vegetative state," 29 agreed wirh the inirial decision to initiate tube feeding and 25 strongly agreed that such feeding should be continued, although none of those surveyed had made the decision to initiate it. Tresch et al., "Patients in a Persistent Vegetative State: Attitudes and Reactions of Family Members," Journal of the American Geriatrics Society, Vol. 39 (January 1991), pp.17-21.

25. Declaration on Euthanasia, Part IV.

26. "In striving to contain medical care costs, ir is important to avoid discriminating against the critically ill and dying, to shun invidious comparisons of the economic value of various individuals to society, and to refuse to abandon patients and hasten death to save money." Hastings Center, Guidelines on the Termination of Life-Sustaining Treatment and Care of the Dying (Hastings Center 1987), p.120.

27. A possible exception is total parenteral feeding. which requires carefully prepared sterile formulas and more intensive daily monitoring. Ironically, some current health care policies may exert economic pressure in favor of TPN because it is easier to obtain third-party reimbursement. Families may pay more for other forms of feeding because some insurance companies do not see them as "medical treatment." See U.S. Congress, Office of Technology Assessment, Life-Sustaining Technologies and the Elderly, OTA-BA-306 (Washington. D.C.: July 1987), p. 286.

28. "One can never claim that one wishes to bring comfort to a family by suppressing one of its members. The respect, the dedication, the time and the means required for the care of handicapped persons, even of those whose mental faculties are gravely affected, is the price that a society should generously pay in order to remain truly human." Document of the Holy See, note 9 supra, 11.1: Origins, p. 748. The Holy See acknowledges that society as a whole should willingly assume these burdens, not leave them on the shoulders of individuals and families.

29. E.g., see P. Singer, "Sanctity of Life or Quality of Life?," Pediatrics, Vol. 72 (July 1983), pp.128-9. On the use and misuse of the term "quality of life" see John Cardinal O'Connor, "Who Will Care for the AIDS Victims?," Origins, Vol. 19 (January 18, 1990), pp. 544-8. Some Catholic theologians agree that a low "quality of life" justifies withdrawal of medically assisted feeding only from patients diagnosed as permanently unconscious. This argument is discussed separately in section 6 below.

30. See David Milne, "Urges MDs to Get Birth Defects Patient's Own Story," Medical Tribune (December 12, 1979), p. 6.

31. National Conference of Catholic Bishops, Pastoral Statement of the United States Catholic Bishops on Persons with Disabilities (Washington, D.C.: USCC 1978).

32. Some patients with disabilities ask for death because all their efforts to build a life of self-respect are thwarted; a "right to die" is the first right for which they receive enthusiastic support from the able-bodied. See Paul K. Longmore, "Elizabeth Bouvia, Assisted Suicide and Social Prejudice," Issues in Law and Medicine, Vol. 3 (Fall 1987), pp.141-168.

33. "Quality of life must be sought, in so far as it is possible, by proportionate and appropriate treatment, but it presupposes life and the right to life for everyone, without discrimination and abandonment." Pope John Paul II, Address of April 14, 1988 to the Eleventh European Congress of Perinatal Medicine: AAS, Vol. 80 (1988), p. 1426; The Pope Speaks, Vol. 33 (1988), pp. 264-5.

34. See Archbishop Roger Mahony, "Two Statements on the Bouvia Case," Linacre Quarterly, Vol. 55 (February 1988), pp. 85-7.

35. Coma and persistent vegetative state are not the same. Coma, strictly speaking, is generally not a long-term condition, for within a few weeks a comatose patient usually dies, recovers, or reaches the plateau of a persistent vegetative state. "Coma implies the absence of both arousal and content. In terms of observable behavior, the comatose patient appears to be asleep, but unlike the sleeping patient, he cannot be aroused from this state.. . . The patient in the vegetative state appears awake but shows no evidence of content, either confused or appropriate. He often has sleep-wake cycles but cannot demonstrate an awareness either of himself or his environment." Levy, "The Comatose Patient," Rosenberg (ed.), The Clinical Neurosciences (Churchill Livingstone 1983), Vol. I, p. 956.

36. While this pejorative connotation was surely not intended by those coining the phrase, we invite the medical profession to consider a less discriminatory term for this diagnostic state.

37. See text: MORAL PRINCIPLES, no.5.

38. Because patients need nutritional support to live during the weeks or months of observation required for responsible assessment of PVS, the cases discussed here involve decisions about discontinuing such support rather than initiating it.

39. One recent scientific study of recovery rates followed up 84 patients with a firm diagnosis of PVS. Of these patients, "41% became conscious by 6 months, 52% regained consciousness by 1 year, and 58% recovered consciousness within the 3-year follow-up interval." The study was unable to identify "predictors of recovery from the vegetative state," that is, there is no established test by which physicians can tell in advance which PVS patients will ultimately wake up. The data "do not exclude the possibility of vegetative patients regaining consciousness after the second year," though this "must be regarded as a rare event." Levin, Saydjari et al., "Vegetative State After Closed-Head Injury: A Traumatic Coma Data Bank Report ," Archives of Neurology, Vol.48 (June 1991), pp. 580-5.

40. Some Catholic moralists, using the concept of a "virtual intention," note that a person may give spiritual significance to his or her later suffering during incompetency, by deciding in advance to join these sufferings with those of Christ for the redemption of others.

41. See: NCCB Committee for Pro-Life Activities, "Guidelines for Legislation on Life-Sustaining Treatment" (November 10, 1984), Origins, Vol. 14 (January 24, 1985); "Statement on the Uniform Rights of the Terminally Ill Act" (June 1986), Origins, Vol. 16 (September 4, 1986); United States Catholic Conference, Brief as Amicus Curiae in Support of Petitioners, "Cruzan v. Director of Missouri Department of Health v. McCanse," U.S. Supreme Court, No. 88-1503, Origins, Vol. 19 (October 26, 1989), pp. 345-351.

42. David Major, M.D., "The Medical Procedures for Providing Food and Water: Indications and Effects," Lynn (ed.), By No Extraordinary Means (Indiana University Press 1986), p. 27.

43. Peripheral veins (e.g., those found in an arm or leg) will eventually collapse after a period of intravenous feeding and will collapse much faster if complex nutrients such as proteins are included in the formula. See U.S. Congress, Office of Technology Assessment, Life-Sustaining Technologies and the Elderly, OTA-BA-306 (Washington, D.C.: U.S. Government Printing Office, July 1987), pp. 283-4.

44. Major, pp. 22, 24-5. Also see OTA, pp. 284-6.

45. See Major, pp. 22, 25-6.

46. Major, p. 22; OTA, pp. 282-3; Ross Laboratories, Tube Feedings: Clinical Application (1982), pp. 28-30.

47. Major, p. 22; OTA, p. 282. Many ethicists observe that there is no morally significant difference in principle between withdrawing a life-sustaining procedure and failing to initiate it. However, surgically implanting a feeding tube and maintaining it once implanted may involve a different proportion of benefit to burden, because the transient risks of the initial surgical procedure will not continue or recur during routine maintenance of the tube.

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