Some moral theologians argue that a particular form of care or treatment is morally obligatory only when its benefits outweigh its burdens to a patient or the care providers. In weighing burdens, they say, the total burden of a procedure and the consequent requirements of care must be taken into account. If no benefit can be demonstrated, the procedure, whatever its burdens, cannot be obligatory. These moralists also hold that the chief criterion to determine the benefit of a procedure cannot be merely that it prolongs physical life, since physical life is not an absolute good but is relative to the spiritual good of the person. They assert that the spirituai good of the person is union with God, which can be advanced only by human acts, i.e., conscious, free acts. Since the best current medicai opinion hoids that persons in the persistent vegetative state (PVS) are incapable now or in the future of conscious, free human acts, these moralists conclude that, when careful diagnosis verifies this condition, it is not obligatory to prolong life by such interventions as a respirator, antibiotics, or medically assisted hydration and nutrition. To decide to omit non-obligatory care, therefore, is not to intend the patient's death, but only to avoid the burden of the procedure. Hence, though foreseen, the patient's death is to be attributed to the patient's pathological condition and not to the omission of care. Therefore, these theologians conclude, while it is always wrong directly to intend or cause the death of such patients, the natural dying process which would have occurred without these interventions may be permitted to proceed.

While this rationale is convincing to some, it is not theoiogically conciusive and we are not persuaded by it. In fact, other theoiogians argue cogently that theological inquiry could lead one to a more carefully limited conclusion.

These morai theologians argue that while particular treatments can be judged useless or burdensome, it is morally questionable and would create a dangerous precedent to imply that any human life is not a positive good or "benefit.' They emphasize that while life is not the highest good, it is always and everywhere a basic good of the human person and not merely a means to other goods. They further assert that if the "burden" one is trying to relieve by discontinuing medically assisted nutrition and hydration is the burden of remaining alive in the allegedly undignified condition of PVS, such a decision is unacceptable, because one's intent is only achieved by deliberately ensuring the patient's death from malnutrition or dehydration. Finally, these moralists suggest that PVS is best seen as an extreme form of mental and physical disability—one whose causes, nature and prognosis are as yet imperfectly understood- and not as a terminal illness or fatal pathology from which patients should generally be allowed to die. Because the patient's life can often be sustained indefinitely by medically assisted nutrition and hydration that is not unreasonably risky or burdensome for that patient, they say, we are not dealing here with a case where "inevitable death is imminent in spite of the means used." Rather, because the patient will die in a few days if medically assisted nutrition and hydration are discontinued, [38] but can often live a long time if they are provided, the inherent dignity and worth of the human person obligates us to provide this patient with care and support.

Further complicating this debate is a disagreement over what responsible Catholics should do in the absence of a final resolution of this question. Some point to our moral tradition of probabilism, which wouid allow individuals to follow the appropriate moral anaiysis that they find persuasive. Others point to the principle that in cases where one might risk unjustly depriving someone of life, we should take the safer course.

In the face of the uncertainties and unresolved medical and theological issues, it is important to defend and preserve important values. On the one hand, there is a concern that patients and families should not be subjected to unnecessary burdens, ineffective treatments and indignities when death is approaching. On the other hand, it is important to ensure that the inherent dignity of human persons, even those who are persistently unconscious, is respected, and that no one is deprived of nutrition and hydration with the intent of bringing on his or her death.

It is not easy to arrive at a single answer to some of the real and personal dilemmas involved in this issue. In study, prayer and compassion we continue to reflect on this issue and hope to discover additional information that will lead to its ultimate resolution.

In the meantime, at a practical level, we are concerned that withdrawal of all life support, including nutrition and hydration, not be viewed as appropriate or automatically indicated for the entire class of PVS patients simply because of a judgment that they are beyond the reach of medical treatment that would restore consciousness. We note the current absence of conciusive scientific data on the causes and implications of different degrees of brain damage, on the PVS patient's ability to experience pain, and on the reliability of prognoses for many such patients. [39] We do know that many of these patients have a good prognosis for long-term survival when given medically assisted nutrition and hydration, and a certain prognosis for death otherwise - and we know that many in our society view such an early death as a positive good for a patient in this condition. Therefore we are gravely concerned about current attitudes and policy trends in our society that would too easily dismiss patients without apparent mentai facuities as non-persons or as undeserving of human care and concern. In this climate, even legitimate moral arguments intended to have a careful and limited application can easily be misinterprered, broadened, and abused by others to erode respect for the lives of some of our society's most helpless members.

In light of these concerns, it is our considered judgment that while legitimate Catholic moral debate continues, decisions about these patients should be guided by a presumption in favor of medically assisted nutrition and hydration. A decision to discontinue such measures shouid be made in light of a careful assessment of the burdens and benefits of nutrition and hydration for the individual patient and his or her family and community. Such measures must not be withdrawn in order to cause death, but they may be withdrawn if they offer no reasonabie hope of sustaining life or pose excessive risks or burdens. We also believe that social and health care policies shouid be carefully framed so that these patients are not routinely classified as "terminal" or as prime candidates for the discontinuance of even minimal means of life support.