The Vaticans recent declaration that vegetative patients have a moral right to feeding tubes exposed a rift among Catholic bishops and church-affiliated providers on the question of when such life support can be stopped for those who are never expected to recover.
Many Catholic ethicists welcomed the statements, released Sept. 14, which said vegetative patients, with few exceptions, have a moral right to a feeding tube (Sept. 17, p. 4). The Vatican went on to single out patients who have no hope of regaining consciousness as equally entitled to such care.
To some, the Vatican merely clarified and cemented its existing policy, but others argued that the Vatican has shifted toward a more restrictive policy on feeding-tube use for patients who are diagnosed as permanently comatose.
It certainly is different from the general practice in the United States and in Catholic healthcare, said Ron Hamel, senior director of ethics for the St. Louis-based Catholic Health Association.
Previously, many regarded feeding tubes as medical care, Hamel argued, a position now at odds with the Vatican, which called artificial nutrition and hydration for vegetative patients ordinary and morally obligatory.
The CHA includes 615 Catholic hospitals, 62 Catholic health systems and more than 550 long-term-care organizations, which follow ethical and religious directives for care and business operations set by the church. Hospitals often arent the ones caring for such patients, as the estimated number of U.S. patients with such a diagnosis is smallroughly 16,000 to 35,000, according to the American Academy of Neurology. Nursing homes provide the bulk of their care, said Catholic health insiders.
Nevertheless, Catholic hospitals should be ready to address the matter. They need to, I would say, examine their practice and develop a policy in light of the Vaticans mid-September statements, Hamel said of Catholic providers. Such a review should also prepare for patients with advanced directives that call for artificial nutrition or hydration be withheld or stopped. There is going to have to be some disclosure to family members upfront that a feeding tube could only be withdrawn under certain circumstances, certain limited circumstances, he said.
Under church teaching, its immoral to deny patients ordinary, or basic, necessary care that supports life and does not unduly burden patients, their families or the healthcare system. But medical treatment goes beyond ordinary measures, according to the church. It may be halted if the overall burdens outweigh the benefits to the patient.
The administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life, said the Vaticans mid-September statement, approved by Pope Benedict XVI, which answered two questions from U.S. bishops. In this way, suffering and death by starvation and dehydration are prevented.
The Vaticans Congregation for the Doctrine of the Faith argued, in an accompanying document, that feeding tubes dont overly burden patients or their relatives; costs for such care arent excessive; an average health system can provide such care, which does not require hospitalization; and artificial nutrition and hydration successfully support patients who cannot feed themselves.
However, the Vatican offered two exceptions. Such care may not be obligatory when it becomes excessively burdensome, as is the case when feeding tubes cause painful or harmful infections. Nor is it necessary if patients cant metabolize food or liquid so that their provision becomes altogether useless, the Congregation said.
Hamel argued that the Vaticans position voices a long-standing but minority view within the church. Now that has become the obligatory view, he said.
Ascension Health, the largest U.S. Catholic health system with 64 acute-care and four long-term-care hospitals, declined an interview request and directed questions to the CHA, as did Trinity Health, Novi, Mich.
Thomas Kopfensteiner, senior vice president of mission at Catholic Health Initiatives, said that the Vaticans statements wont alter policies at the Denver-based system, which owns 71 hospitals and 43 long-term-care, assisted living or residential facilities. Its a clarification, said Kopfensteiner, who helped draft the Catholic ethical and religious directives issued by the U.S. Conference of Catholic Bishops. Nothing changed. In practice, nothing changed.
Other major Catholic systems also declined to comment, including SSM Health Care, St. Louis, and Providence Health & Services, Seattle. Christopher Sutton, an SSM spokesman, said the system, which owns and operates 16 acute-care and two long-term-care hospitals, doesnt routinely care for patients in a vegetative state.
Richard Doerflinger, deputy director of the Secretariat for Pro-Life Activities for the U.S. Conference of Catholic Bishops, rejected arguments that the recently released statements break from prior church teachings. The statement, he said, instead clarified the churchs position and outlined a few conditions, expected to be rare, when it is permissible to remove artificial nutrition and hydration. This is something we owe people because of human dignity, Doerflinger said.
U.S. bishops asked the Vatican to clarify the churchs policy on artificial nutrition and hydration for vegetative patients in July 2005, after courts and Congress became battlegrounds in a legal and political clash over the removal of a feeding tube from Terri Schiavo.