Turning Off a Ventilator versus Withdrawing Assisted Nutrition and Hydration
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Catholic bioethicists can draw on a remarkable intellectual tradition going back centuries that helps them make important distinctions in ethical reasoning. One that puzzles many people, including some medical professionals, is the widely accepted Catholic position that there are many more circumstances where it is ethically acceptable to turn off a ventilator than there are to suspend providing food and water, even if administered by artificial means. At first glance it seems that air to breathe is even more urgently needed for keeping a patient alive than water or nutrition. This is quite true, but use of a ventilator is a different kind of care than administering food and water.
The question about what can or cannot be ethically withdrawn from a patient relies on an analysis using the Catholic distinction between ordinary and extraordinary care. The first is morally required and the latter is optional. The underlying principle is that there is no right to suicide. In fact, we have a moral obligation to use all the normal or ordinary means at our disposal to preserve our lives because human life is a precious gift from God and has a sacred character. Extraordinary care, sometimes called disproportionate care, involves a large imbalance between the anticipated benefits vs. the probable burdens of a proposed course of action. I wrote about this distinction before, emphasizing that the Church refuses to “place stricter obligations on people than what is morally required.” Christ in the Gospels rebuked the religious authorities of his day for putting heavy burdens on people and not lifting a finger to help (Mt 23:4).
The Catholic bioethical view that ventilators are mainly extraordinary care comes from the way they work. Mechanical ventilators do not just provide oxygen but take over the function of the diaphragm to actively fill and empty the lungs with air, in effect, replacing some of the natural acts that are integral to respiration. In contrast to ventilator care, simply providing oxygen through a tube or mask is similar to administering hydration through an IV or nutrition through a feeding tube. All provide something our bodies need to survive without taking over or even heavily assisting the functioning of organs. I think there is a strong case to be made that providing oxygen through a tube is usually ordinary care.
If a patient needs a ventilator as a bridge to recover from an operation or illness, or during resuscitation, the heavy burden of its use can easily be justified. But if the patient is dependent on ventilator support to breathe and it seems unlikely he will ever be capable of being weaned of it, this presents a harder ethical dilemma. He will be kept alive by artificial means that heavily assist a vital function and pose a significant burden. This more closely fits the definition of extraordinary care, which can be chosen but one is not morally obligated to receive. There could be many compelling reasons or circumstances to continue ventilator support for a time, but the Church rejects the assertion that turning it off in a situation of extraordinary care is killing the patient. Extraordinary care can be chosen, it is just that we are not ethically required to accept it. There are clearly cases where the action of turning off a ventilator is allowing a person to die a natural death, which is heart wrenching but not a violation of the moral law.
Having a patient die of dehydration or malnutrition because of withdrawing or refusing to provide food and water by artificial means was declared a violation of the moral law by the Congregation for the Doctrine of the Faith in 2007. Nothing similar has come from Rome regarding patients dying from withdrawal of ventilator support. Simply providing nutrition or hydration by a tube does not change the fact that the patients are assimilating/digesting what is provided. Similarly, there is no lack of oxygen to breathe in a patient’s room. The need for a ventilator occurs when the person is unable to ventilate/respirate adequately on his own and needs assistance. By taking this additional step of assisting the patient to breathe, ventilators become a medical act that is subject to the analysis of whether it is an ordinary or extraordinary means of medical care.
I hope you agree with me that it is incredibly useful to be able to apply Catholic bioethical principles to make fine but key distinctions that have very practical, real world consequences regarding end-of-life care. Chapter 23 of the NCBC’s Catholic Health Care Ethics: A Manual for Practitioners discusses the differences between the use of ventilators and the artificial provision of food and water and many other end-of-life questions in greater detail. I highly recommend the NCBC’s health care manual if you find these kinds of ethical questions fascinating.
