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About Medicine & Morality

SEPTEMBER 2000

PROVIDING NUTRITION AND HYDRATION TO PATIENTS

A Catholic Perspective

by Julie Grimstad

Julie A. Grimstad has been Director of the Center for the Rights of the Terminally Ill for the past 15 years. Her early experiences as a nurse in an extended care unit of a hospital, as well as having had a brother with a severe mental disability, contributed to her concern for the human rights of the medically dependent, vulnerable people who often feel (and are) rejected by a society that increasingly values only its healthy and productive members. Julie is a Wisconsin homemaker, wife, mother of five and grandmother of 2 children.

Mrs. Grimstad is also the author of "Euthanasia: Imposed Death" (copyright 1997, 1998, 1999, 2000), a newspaper supplement covering such topics as so-called "Persistent Vegetative State", witholding food and water from disabled people, Who's Who in the Right-to-Die Arena, etc.

This column, to appear in a forthcoming issue of the American Life League's magazine, Celebrate Life, is her first contribution to WFF's "About Medicine and Morality". -- Editor


Contrary to what secularists (1) claim, there are absolutes - absolutely right and absolutely wrong choices and actions. More than any other entity in the world, the Catholic Church unambiguously proclaims this truth, particularly in regard to the sanctity and inviolability of human life. It is time for "those who have ears to hear" to listen to a voice that has not waffled on the truth in 2000 years.

"All crimes against life, including euthanasia or willful suicide, must be opposed." ­ Congregation for the Doctrine of the Faith, Declaration on Euthanasia, May 5, 1980

"Euthanasia in the strict sense is understood to be an action or omission which of itself and by intention causes death, with the purpose of eliminating all suffering." ­ ­ John Paul II, Evangelium Vitae (The Gospel of Life), March 25, 1995

Joseph Fletcher, the father of Situation Ethics (2) and president of the Society for the Right to Die, was fond of telling audiences that just as we practice birth control, we must practice death control to get rid of "subhuman life in extremis." (One might wonder at what age one becomes "subhuman", since Fletcher lived into his 90's.)

On the other hand, the Catholic Church has consistently taught that, just as artificial birth control is always wrong, death control is always wrong.

"Nothing and no one can in any way permit the killing of an innocent human being, whether a fetus or an embryo, an infant or an adult, an old person, or one suffering from an incurable disease, or a person who is dying. Furthermore, no one is permitted to ask for this act of killing, either for himself or herself or for another person entrusted to his or her care, nor can he or she consent to it, either explicitly or implicitly. Nor can any authority legitimately recommend or permit such an action."
­ Evangelium Vitae

Practically speaking, this means: "Thou shalt not kill." So, how do we apply this commandment to real life situations confronting us today?

A man lapsed into a coma after surgery for a ruptured brain aneurysm. He suffered permanent, profound brain damage, but was not dying. He was being fed through a gastrostomy tube (3). Some people, including his wife, thought he would not want to live like that and suggested that withdrawing food and fluids from him would be in his best interest. What was the right thing to do?

The Church teaches that omitting medical care or treatment with the intent to cause the death of a person is always wrong. In fact, the following statement by the Committee for Pro-Life Activities of the National Council of Catholic Bishops (1992) demonstrates that our Bishops understand the motives of those who advocate withdrawing food and fluids from patients.

"Nutrition and hydration (whether orally administered or medically assisted) are sometimes withdrawn not because a patient is dying, but precisely because a patient is not dying (or not dying quickly enough) and someone believes it would be better if he or she did, generally because the patient is perceived as having an unacceptably low 'quality of life' or as imposing burdens on others."

The Bishops were not just whistling in the dark. Numerous "right to die" court decisions have granted permission for people, such as our man with permanent brain damage (4), to be starved and dehydrated to death simply because someone (their father, wife, physician,) perceived these people as having low "quality of life" or as being a burden.

"A great teaching effort is needed to clarify the substantive moral difference between discontinuing medical procedures that may be burdensome, dangerous or disproportionate to the expected outcome ­ what the Catechism of the Catholic Church calls the 'refusal of overzealous treatment' ­ and taking away the ordinary means of preserving life, such as feeding, hydration and normal medical care." ­ ­ ­ John Paul II, Oct. 2, 1998.

Furthermore, the Pope stated that the "presumption would be in favor of providing medically assisted nutrition and hydration to all patients who need them."

In the past fifteen years, I have researched and studied almost everything those in positions of authority in the Church have written or said regarding this issue. The most important conclusion I have reached is that one should err on the side of life when any doubt exists about what the right decision is in a given situation. Additionally, I submit the following "rules" as a summary of what I have learned about how to make moral decisions regarding the provision or withdrawal of food and fluids, whether administered orally or through a tube:

1. Food and fluids are not medical treatment because they do not cure; they sustain life. If nutrition and hydration are discontinued, the patient will die because a new cause of death ­ deliberately intended starvation and dehydration -- has been introduced.

2. Tube-feeding persistently unconscious patients is morally obligatory in most cases since it is clearly beneficial in terms of the preservation of life and usually does not add a serious burden (excessive pain, expense, etc.).

3. For terminally ill patients, the provision of food and fluids, so long as they can be assimilated (absorbed into the system of the body), must be considered ordinary / obligatory care, and not as a medical treatment. There may be an occasional exception to this "rule" if the patient himself finds the means necessary to administer food and fluids to be excessively burdensome.

4. When death is so close (5) that further nutrition and hydration will do the patient no good, food and fluids may be discontinued if the patient is more comfortable without them.

In 1988, the Catholic Conference of Kentucky warned: "some of the proponents of living will legislation intend to use such a bill as a stepping stone to the systematic murder of the elderly ill and infirm." Since the first "living will" law was enacted in California in 1976 (6), such state laws have been amended and their scope expanded repeatedly, until one must see the wisdom in paying attention to that warning.

For instance, Wisconsin's Living Will and Durable Power of Attorney for Health Care laws now allow signers to refuse food and fluids provided through feeding tubes in case of either a "terminal condition" or "persistent vegetative state" (PVS) (7). "Terminal condition" is vaguely defined in terms of "an incurable condition" that "would cause death imminently". In 1983, the Wisconsin Living Will law allowed "life-sustaining procedures" to be withheld if the patient had a 30-day life expectancy. Considered too restrictive, the definition was amended in 1986 to "would cause death imminently", language which could be more broadly interpreted (8). Furthermore, the more recent expansion of the Wisconsin law (as well as a number of other states' laws) to allow food and fluids to be taken away from PVS patients contradicts the Sanctity of Life Ethic of the Catholic Church, as well as many other religious bodies, and embraces the Quality of Life Ethic of the secularists.

What was / is the ultimate purpose for enacting laws that allow patients to be killed by starvation and dehydration?

The answer to that question was provided at the 1984 World Federation of Right to Die Societies fifth biennial conference by Helga Kuhse, Ph.D., a bioethicist at Monash University, Melbourne, Australia. She explained:

"If we can get people to accept the removal of all treatment and care, especially the removal of food and fluids, they will see what a painful way this is to die, and then, in the patient's best interest, they will accept the lethal injection."

Dr. Kuhse articulated the role the "living will" had been designed to play. "Living will" laws are very much responsible for the destruction of traditional medical ethics in the U.S. and around the world. The discussion is no longer about whether or not killing the medically vulnerable should be allowed. It is now about what criteria should be used to decide who will be killed and what means should be used to kill them.

This pro-death mood has given rise to a DUTY TO DIE. As proof, I call your attention to the recent adoption by many hospitals of "Futile Treatment Policies", sometimes called "Non-beneficial Care Policies", which allow hospitals to deny life-sustaining treatment and care, including tube-feeding, to patients who want it. State laws are following suit.

In 1999, the Texas "living will" / durable power of attorney for health care law was amended to include a policy which states:

"If the patient is requesting life-sustaining treatment that the attending physician and the review process have decided is inappropriate treatment, the patient shall be given available life-sustaining treatment pending transfer. The physician and the health care facility are not obligated to provide life-sustaining treatment after the 10th day after the written decision is provided to the patient or the person responsible for the health care decisions of the patient unless ordered to do so"

A court can order an extension of the time period, at the request of the patient or his agent, only if it finds that there is a reasonable expectation that a physician or health care facility that will honor the patient's request for treatment will be found in the time granted.

This all very simply means that a very ill person who is notified that his doctor and hospital doesn't think his life is worth sustaining has 10 days (barring a court ordered extension) to desperately search for a doctor or hospital. If the search is fruitless, the person will be killed by withdrawal of life-sustaining treatment, including tube-feeding. And, no, "killed" is not too strong a word, because the Texas law says:

"'Life-sustaining treatment' means treatment that, based on reasonable medical judgment, sustains the life of the patient and without which the patient will die."

To take away treatment "without which the patient will die" is to intentionally cause the death of (kill) the patient. When a "Futile Treatment Policy" is implemented, involuntary euthanasia is the outcome.

That, my friends, is a DUTY TO DIE imposed on poor souls who, for all intents and purposes of the law, are deemed "useless eaters" (9). What are we, who do not want a "right to die" (more accurately, a duty to die), to do? What are we, who believe it is absolutely wrong to kill people whether by an action or omission, to do in order to restore the Sanctity of Life Ethic to our laws and medical practices?

1. Pray and fast. Jesus Himself has shown us that prayer and fasting are the most effective weapons against the forces of evil.

2. Become informed about this issue and speak about it to relatives, friends, neighbors, your church groups, etc.

3. Make health care decisions for yourself and others based on what the Catholic Church teaches rather than on your own inclinations to avoid what is unpleasant by opting for a quick death. This is both an effective witness to others and a message to the medical profession that some people do not want the "right to die" because they have faith in God and recognize that His law must be obeyed

4. Be a Good Samaritan. Visit the sick, disabled and elderly. Befriend and protect them. "A Good Samaritan is one who brings help in suffering. He puts his whole heart into it, nor does he spare material means. Man cannot fully find himself except through a sincere gift of himself. A Good Samaritan is the person capable of exactly such a gift of self."
­ Pope John Paul II, Salvifici Doloris.

Consider carefully these words of Our Holy Father in the introduction to Evangelium Vitae (The Gospel of Life):

"The present encyclical, the fruit of the cooperation of the episcopate of every country of the world, is therefore meant to be a precise and vigorous reaffirmation of the value of human life and its inviolability, and at the same time a pressing appeal addressed to each and every person, in the name of God: respect, protect, love and serve life, every human life! Only in this direction will you find justice, development, true freedom, peace and happiness!"



Endnotes

1. Secularist: A person who believes in the doctrine of "Situation Ethics", that is, simply put, that there are no absolutes; what is right or wrong depends on the situation. For example, according to this view, in the situation of a terminally ill person who is in pain, assisted suicide is good. Generally, a secularist either believes there is no God, or, if He does exist, He is irrelevant to moral decision-making.

2. Situation Ethics: See footnote 1.

3. Gastrostomy tube: A tube inserted into the stomach through a small surgical opening in the abdominal wall. This is neither a new nor an overzealous measure. An 1896 Kentucky State Medical Society Journal shows a photo of a young boy living successfully with a G-tube and explains the surgical procedure. Many people who need G-tubes have full-time jobs and lead active lives.

4. Paul Brophy, a Massachusetts firefighter, died on 10/3/86, eight days after medical personnel stopped his G-tube feedings with approval of the Supreme Court of Massachusetts.

5. "When death is so close": Beware the phrase "would cause death imminently" and similar terms such as "imminently dying". Many of us understand such terms to mean progressive and rapid deterioration so that the patient is expected to die within a few hours, or a few days, at most. However, courts and hospitals have interpreted "imminently dying", as used in "living will" laws, to include persons who are expected to live for months and even as long as a year.

6. The "living will": More accurately called a "refusal of treatment document", the "living will" was formulated and promoted by "right to die" groups which viewed it as a stepping stone to social and legal acceptance of full-scale euthanasia/assisted suicide.

7. "Persistent vegetative state" (PVS) is a diagnosis used to describe a person who has an extreme form of mental and physical disability. It is the only medical diagnosis that contains a pejorative term. People are not vegetables! This diagnosis tends to obscure a person's dignity and value.

8. See footnote 5.

9. "Useless eaters": a term used to describe those slated for death (often death by starvation) by the Nazis.


Related Statement
Taking a stand against causing death, March 2,2005


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