Revision of Directive 58 of Ethical and Religious Directives for Catholic Health Care Services
After careful deliberation, the United States Conference of Catholic Bishops has revised directive 58 of the Ethical and Religious Directives for Catholic Health Care Services (2001). Here is the language of the new directive in the fifth edition:
In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic and presumably irreversible conditions (e.g., the "persistent vegetative state") who can reasonably be expected to live indefinitely if given such care. Medically assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be "excessively burdensome for the patient or (would) cause significant physical discomfort, for example resulting from complications in the use of the means employed." For instance, as a patient draws close to inevitable death from an underlying progressive and fatal condition, certain measures to provide nutrition and hydration may become excessively burdensome and therefore not obligatory in light of their very limited ability to prolong life or provide comfort.
The bishops also deleted language in the introduction to Part V, “Issues in Care for the Dying,” that indicated the need for “further reflection” on whether nutrition and hydration should be provided for patients in a persistent vegetative state.
The new language of the directive follows the clarification of Church teaching on this matter that began with John Paul II’s “Address on Life-sustaining Treatments and the Vegetative State: Scientific Advances and Ethical Dilemmas” (March 20, 2004), and more recently, the statement of by the Congregation for the Doctrine of the Faith, “Responses to Certain Questions of the USCCB concerning Artificial Nutrition and Hydration" (August 1, 2007). These documents did not advance any new teaching, but reemphasized the long-standing view within the Church that patients are entitled to minimal standards of care in any hospital setting, including clean bedding, warmth, food and water, and other basic necessities.
In his address on life-sustaining treatments, John Paul II stated: “I should like particularly to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering” (no. 4).
Some have misunderstood this passage. By describing the administration of food and water, even when delivered by artificial means, as a “natural means of preserving life, not a medical act,” the Holy Father was not saying that no medical assistance is needed to place and maintain a feeding tube, but that food and water are natural necessities of the human condition. They are not part of any medical treatment and do not cure any disease. They are part of the normal care due to any human being, whether healthy or ill.
John Paul’s words were directed to the care of patients in the persistent vegetative state, and against the practice of removing food and water from these patients on the grounds that they do not possess sufficient cognitive function to engage in the spiritual purpose of life. Patients with debilitated consciousness are not dying, and the fact that they suffer cognitive diminishment or failure is not a reason to deprive them of food and water. When food and water are taken from them, these patients die from a lack of nutrition and hydration. As John Paul II said: “Death by starvation or dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission.”
This teaching was reiterated by the Congregation for the Doctrine of the Faith in its Responses, which stated that “The administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life. It is therefore obligatory to the extent to which, and for as long as, it is shown to accomplish its proper finality, which is the hydration and nourishment of the patient. In this way suffering and death by starvation and dehydration are prevented.” While the CDF was responding to questions pertaining to those in the persistent vegetative state, the accompanying commentary drew a parallel to the duty not to abandon those unable to take care of themselves: “a quadriplegic, someone with serious mental illness, with advanced Alzheimer’s disease, and so on.” The Responses also affirmed that a patient who lacks consciousness “is a person with fundamental human dignity and must, therefore, receive ordinary and proportionate care which includes, in principle, the administration of water and food even by artificial means.”
The CDF Responses also took great pains, through an accompanying explanatory narrative, to show how this teaching is consistent with past magisterial statements from the Church on the care of patients. There has been no departure from previous teaching, including that of Pope Pius XII and his predecessors. Some have argued that the moral imperative to provide food and water to those who suffer from cognitive disabilities, recently reiterated by the Church, represented a sharp break from previous tradition, but that is not the case. Rather, some came to expect that the Church would revise its views in this matter, and have been disappointed.
Others have contended that the recent statements from the Vatican apply solely to patients in the persistent vegetative state, and that other patients who suffer from similar maladies, and are likewise unable to communicate effectively with others, or even able to communicate at all, are not included under this directive. Again, that is not the case. Any patient who suffers a cognitive disability, whether major or minor, should receive nutrition and hydration unless there are clear indications that it will not provide sufficient benefits to outweigh the burdens. Here the benefit is life itself.
Catholic health care facilities have an obligation to review their protocols concerning the provision of food and water to those who have suffered a serious cognitive diminution. Policies that routinely remove food and water from patients who have suffered this loss are clearly inappropriate.[1] There are exceptions, such as when “artificial nourishment and hydration may be excessively burdensome for the patient or may cause significant physical discomfort, for example resulting from complications in the use of the means employed.” However, food and water should generally be provided to all patients, regardless of their cognitive condition. Catholic facilities should be aware that general medical practice is not necessarily following Church teaching in this area, and so they should be prepared to distinguish their own practice from the growing tendency to deprive certain patients, especially the elderly, of the basic necessities to sustain life.
Catholic health care facilities will also need to reevaluate patient requests, whether oral or written, that they be deprived of food and water in the event that they fall into an unconscious state from which they may not recover. The return of records and transfer of patients may be necessary in such cases. Also, the Catholic faithful will need to reexamine their advance directives and living wills to ensure that they have not agreed to deprive themselves of food and water simply because they have become cognitively disabled.
1. The National Catholic Bioethics Center has developed a “Model Policy Concerning the Care to Patients at Life’s End for Catholic Health Care Agencies.”
