Tube Feeding: Catholics in Southern California

Do End-of-Life Guidelines in Los Angeles Differ from Catholic Teaching?

The article on Advance Directives has a section on "Talking with Doctors," which mentions guidelines for compassionate care in Los Angeles and southern California, including Providence, a Catholic hospital chain. The article also mentions Catholic teaching on artificial feeding. 

Fr. Luke Dysinger has been kind enough to explain how these guidelines that doctors "are not obliged to offer" feeding tubes relate to Catholic teaching that providing food is obligatory "even by artificial means." Fr. Dysinger is a professor at a Catholic seminary, and was on the program for a press conference announcing the guidelines. Nine major health systems adopted the guidelines in May 2014, including a Catholic group which runs 6 hospitals, Providence Health & Services.

The joint guidelines say that doctors "are not obliged to offer" tube feeding:

• "In patients with late-stage terminal illness, use of interventions such as... intravenous feeding, gastric food feeding... are generally non-beneficial and may cause an increase in pain and suffering (i.e. harm)." (footnote 5, emphasis added)
• And the guidelines say doctors "are not obliged to offer or provide medically non-beneficial treatment" (section 4).

 
The Vatican said in 2007 (approved in 2007 by Pope Benedict XVI, building on earlier teaching by Popes John Paul II and Pius XII): 

• "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."
  

www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_20070801_risposte-usa_en.html
Official Commentary: www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_20070801_nota-commento_en.html

Fr. Dysinger wrote:

Thank you for your question concerning Catholic teaching on the necessity of nutrition and hydration at the end of life. The short answer to your question lies in the very important words "in principle" within the statement you quoted. The original Italian for this phrase is "in linea di principia" (Pope John Paul II, "Life Sustaining Treatment..." Mar. 20, 2004; reference and citation below) which, as I understand it, can also be translated as "normally", or "generally speaking". Thus the statement does not – and in fact could not – make an absolute statement that artificial nutrition and hydration must always be used in any clinical setting. There is not, nor could there ever be, such a thing as a "Vatican-approved" list of modalities that are always obligatory or always optional for all Catholics. Everything depends on the unique circumstances of the case and the informed desires and moral intentions of the patient. A key summary of Catholic moral teaching on this point may be found in the Catechism of the Catholic Church: 

§2278. Discontinuing medical procedures that are burdensome, dangerous, extraordinary (onerosis, periculosis, extraordinariis), or disproportionate to the expected outcome can be legitimate; it is the refusal of "over-zealous" treatment. Here one does not will to cause death; one's inability to impede it is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected.

For many centuries the Catholic Church has emphasized that the definition of "burden" in any particular setting can only be made by the patients themselves (i.e. not by the physician or the clinical ethicist), and that as long as the patient does not intend to cause or hasten death by refusing treatment (whether understood as "medical acts" or "natural means") , such refusal may be permissible if the patient finds the means or acts morally repugnant (St. Alphonsus M. de Liguori Theologia Moralis Tractate 4. On the Fourth and Sixth Precepts [of the Decalog]. Ch. 1, "What is forbidden by the Precept: You shall not kill", § 366-372. original text with translation: http://ldysinger.stjohnsem.edu/ThM_590_Intro-Bioeth/03_hist-devt/05_enlightenment.htm#4._ALPHONSUS_LIGOURI_ )

So the short answer to the polemical question "Are dying Catholics obliged to have feeding tubes," is "no, they are not, unless they want them." I have never met a trained provider of palliative care who recommended or encouraged parenteral feeding for the dying; and it should be added that the Catholic Church is extremely supportive of palliative care, as is stated quite strongly in the Catechism:

§2279 Even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted​. The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only foreseen and tolerated as inevitable Palliative care is a special form of disinterested charity. As such it should be encouraged.

But your question merits a longer answer (as if the foregoing were not long enough!) The statement you have quoted concerning the necessity for nutrition and hydration first occurred in an address of Pope John Paul II entitled "Life-Sustaining Treatment and the Vegetative State: Scientific Progress and Ethical Dilemmas" (March 20, 2004: http://www.vatican.va/holy_father/john_paul_ii/speeches/2004/march/documents/hf_jp-ii_spe_20040320_congress-fiamc_it.html). It was clearly the pope's intention to address the then-popular conviction among secular ethicists that it is morally permissible (or even obligatory) to discontinue nutrition and hydration of patients in the persistent vegetative state. The pope's response in this document is fairly detailed, and most specifically emphasizes that PVS patients are not dying, but are, rather, profoundly disabled; and the pope urges that they be treated as we would treat any other disabled persons who are unable to feed or otherwise care for themselves. 

The pope also pointed out that PVS is a syndrome rather than a disease, that it is often misdiagnosed, and that we do not, in fact, know with certainty what level of consciousness may be present, even in patients who are correctly diagnosed as being in a persistent vegetative state. This last point is crucial, since a fundamental difference (from the standpoint of care) between dying patients and those who are not dying, is that the dying often refuse food and water, yet do not suffer from a subjective sense of thirst or hunger. This would not be the case in an apparently-"vegetative-state" person who nevertheless retained some level of awareness and sensation. There can be little doubt that such a person would, in fact, suffer very great pain from dehydration and starvation if artificial feeding were simply stopped. Recent research published in reputable medical journals (Neurology, the New England Journal of Medicine) has revealed the pope to have been alarmingly correct: a significant percentage of correctly-diagnosed PVS patients are apparently able to understand and properly respond to verbal commands. Needless to say, ethicists who formerly argued that PVS patients should not be provided with nutrition and hydration ought to more carefully nuance their arguments on the basis of these findings: 

["Willful Modulation of Brain Activity in Disorders of Consciousness" Monti et.al., NEJM Feb. 3, 2009, 579-589: 
http://www.cogsci.msu.edu/DSS/2011-2012/Owen/Monti%20et%20al.%202010%20NE%20J%20of%20Medicine.pdf . "Probing Consciousness with Event-Related Potentials in the Vegetative State" Faugeras and Rohout, Neurology 77:264–268, July 19, 2011: http://www.unic.cnrs-gif.fr/media/pdf/FaugerasNaccache_Neurology_2011.pdf

So it was in the context of a discussion of the persistent vegetative state, not the terminally-ill or imminently-dying patient, that Pope John Paul stated in the document cited above:

(§4) The sick person in a vegetative state, awaiting recovery or a natural end, still has the right to basic health care (nutrit​ion, hydration, cleanliness, warmth, etc.), and to the prevention of complications related to his confinement to bed. He also has the right to appropriate rehabilitative care and to be monitored for clinical signs of eventual recovery. 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. 

The pope's words have been misconstrued by Catholics and non-Catholics alike as constituting an obligation to use parenteral nutrition. And it was, perhaps, for this reason, that six months later (and shortly before his own death) Pope John Paul II issued another document in which he described and praised palliative care. I hope you do not mind if I quote the relevant section in full: perhaps you will find it useful in your own work:

4. True compassion, on the contrary, encourages every reasonable effort for the patient's recovery. At the same time, it helps draw the line when it is clear that no further treatment will serve this purpose. 

The refusal of aggressive treatment is neither a rejection of the patient nor of his or her life. Indeed, the object of the decision on whether to begin or to continue a treatment has nothing to do with the value of the patient's life, but rather with whether such medical intervention is beneficial for the patient. 

The possible decision either not to start or to halt a treatment will be deemed ethically correct if the treatment is ineffective or obviously disproportionate to the aims of sustaining life or recovering health. Consequently, the decision to forego aggressive treatment is an expression of the respect that is due to the patient at every moment. 

It is precisely this sense of loving respect that will help support patients to the very end. Every possible act and attention should be brought into play to lessen their suffering in the last part of their earthly existence and to encourage a life as peaceful as possible, which will dispose them to prepare their souls for the encounter with the heavenly Father. 

5. Particularly in the stages of illness when proportionate and effective treatment is no longer possible, while it is necessary to avoid every kind of persistent or aggressive treatment, methods of "palliative care" are required. 

["Address of John Paul Ii to the Participants in the 19th International Conference of the Pontifical Council for Health Pastoral Care" Friday, 12 November 2004; http://www.vatican.va/holy_father/john_paul_ii/speeches/2004/november/documents/hf_jp-ii_spe_20041112_pc-hlthwork_en.html ]

This second document is not as well-known or frequently cited as the one concerning PVS, but I believe it is essential to read both together.

Question Remaining

Fr. Dysinger makes a strong point above that Catholicism teaches tube feeding is a moral choice for patients to make:,

• "definition of "burden" in any particular setting can only be made by the patients themselves (i.e. not by the physician or the clinical ethicist),"
• "refusal may be permissible if the patient finds the means or acts morally repugnant",
• and quoting the Catechism, "decisions should be made by the patient if he is competent and able."

How can the guidelines say, "Physicians... are not obliged to offer" a list of treatments which includes tube feeding (section 4 and footnote 5)? The guidelines let doctors choose, not necessarily the competent patient. As Rubin wrote, "At its heart the futility debate is a debate about power, who should have it, and how it should be exercised."