And talk about saturated media coverage. The Corner at National Review Online was all-Schiavo, all the time. Fox News resident clown Sean Hannity was camped out in Florida. It was an interesting time, given what was going on in Iraq and the unprecedented legalization of torture in the United States, but no, Terry Schiavo was the issue. And the worst part about it was the pervasive belief that this was a Catholic issue. Even today, peruse the Catholic blogosphere and you will see frequent references to the "murder" and "starvation" of Terry Schiavo.
We need to take a step back and figure out what went on. First and foremost, there was a profound (and willful?) misunderstanding of Catholic end of life teachings by many of the protagonists. Certainly, the church condemns euthanasia as a grave evil. As the Catechism (#2277) notes: "Whatever its motives and means, direct euthanasia consists in putting an end to the lives of handicapped, sick, or dying persons. It is morally unacceptable. Thus an act or omission which, of itself of by intention, causes death in order to eliminate suffering constitutes a murder gravely contrary to the dignity of the human person and to the respect due to the living God, his Creator." Pope John Paul II rightly referred to euthanasia as an integral component of the culture of death.
But it's complicated. Again, to the Catechism (#2278): "Discontinuing medical procedures that are burdensome, dangerous, extraordinary, 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. And #2279 says: "Even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted".
What does all of this mean? Well, ordinary means morally obligatory, and extraordinary means optional. Let's look more deeply at this issue, to the 1980 Declaration on Euthanasia, which states:
"Therefore one cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community."There is a long moral tradition suggesting that there is no moral obligation to undergo whatever it takes to prolong life. Way back in the 4th century, St. Basil wrote: "Whatever requires an undue amount of thought or trouble or involves a large expenditure or effort and causes our whole life to revolve, as it were, around solicitude for the flesh must be avoided by Christians."
The distinction between ordinary and extraordinary care was developed in the 16th century. As described with great clarity by Brother Daniel Sulmasy, intervention can be judged extraordinary and disproportionate if it is "too expensive, not likely to work, is associated with great suffering, or might save the patient's life at too great a psychological, spiritual, or interpersonal cost". St. Alphonsius Ligouri wrote that if sustaining life required eating rich food, that was not required. A friend of mine uses the example of St. Antoninus of Florence who told a man he was not morally obliged to have his leg amputated and live as a cripple, even if not doing so (the leg probably was gangrenous) would bring about his death. The same reasoning guided later moralists when it came to ventilators and feeding tubes. Indeed, the 16th century Dominican Francisco de Vitoria wrote: "I would say that if the depression of the spirit is so low and there is present such consternation in the appetitive power that only with the greatest of effort... can a sick man take food, right away that is reckoned a certain impossibility, and therefore he is excused". In 1957, Pope Pius XII made a similar argument relating to the use of ventilators.
One of the leading authorities in this area is Fr. John Paris S.J., a Jesuit bioethicist, who has written on this topic, relating how it played out in the United States over the past 50 or so years. See: "The Catholic Tradition and the Use of Nutrition and Fluids," by John J. Paris, S.J., in Birth, Suffering, and Death, edited by Kevin Wildes, 1992, Kluwer Academic Publishers. Here are some of the highlights:
Daniel Cronin's doctorate from the Gregorian in 1958 (he was later archbishop of Hartford, Mass.) noted that after a thorough review of over 50 moralists from Aquinas to the 1950s, "even natural means, such as taking of food and drink, can become optional if taking them requires great effort or if the hope of beneficial results (spes salutis) is not present".Indeed, church guidelines in the United States reflected these considerations. In 1987, the pro-life committee of the U.S. Catholic Conference declared that "laws dealing with medical treatment may have to take account of exceptional circumstances where even means of providing nourishment may be too ineffective of burdensome to be obligatory." The Texas bishops adopted official guidelines in 1990, noting that patients in a PVS can have such treatment withdrawn, and that this is "not abandoning the person. Rather, it is accepting the fact that the person has come to the end of his or her pilgrimage and should not be impeded from taking the final step."
Gerald Kelly S.J., possibly the leading moralist of his day stated in 1950 that "no remedy is obligatory unless it offers a reasonable hope of checking or cusing a disease". He also said ""I'm often asked whether you have to use IV feeding to sustain somebody who is in a terminal coma. Not only do I believe there is no obligation to do it, I believe that imposing those treatments on that class of patients is wrong. There is no benefit to the patient, there is great expense to the community, and there is enormous tension on the family."
Moralist Albert Moraczewski, O.P. noted "There appears to be no strict ethical obligation to provide nourishment by such technological interventions as intubation."
Fr. Robert McManus, asked to advise Biship Gelineau (Providence, Rhode Island) on a case involving a Catholic in a persistent vegetative state (PVS) for 2 years on the morality of removing life-sustaining nutrition and fluids, stated: "The medical treatments which are being provided the patient, even those which are supplying nutrition and hydration artificially, offer no reasonable hope of benefit to her. This lack of reasonable hope or benefit renders the artificially invasive medical treatments futile and thus extraordinary, and disproportionate and unduly burdensome. Moreover, the continuation of such medical treatments is causing a significant and precarious economic burden to [the patient's] family. It must be unambiguously clear that the primary intention of removing what has been competently judged to be extraordinary means of artificially prolonging the patient's natural life is to alleviate the burden and suffering of the patient and not to cause her death."
It seems quite clear: providing food and water can sometimes be seen as extraordinary and disproportionate measures, justifying removal of tubes. This is most assuredly not euthanasia. In particular, if the person is unconscious with no hope of recovery, and cannot feel pain, then removal is licit. It was quite clear that these conditions were met in Terry Schiavo, who was in a PVS. She was not interacting or communicating with anybody. The autopsy (sorry, Bill Frist) showed she had "massive and irreversible brain damage and was blind".
However, it gets even more complicated! Especially given recent advances in the quality of healthcare, many have argued that the provision of food and water should be considered ordinary care, and thus morally obligatory. The 2001 Ethical and Religious Directives for Catholic Health Care Services of the United States Conference of Catholic Bishops reflects this tension, noting "there should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient."
Pope John Paul II weighed in on this issue in May 2004. In an allocution at a conference, he argued that artificial nutrition and hydration were "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."
First things first. As Brother Daniel Sulmasy notes, it is not the case that anything a pope sayss becomes instant dogma, as popes are "also bound by our common tradition". Br. Daniel explains that a group of Catholic scholars met in 2004 to discuss these issue in light of the pope's speech. First, they note, "in principle" does not mean without exception. All the pope is saying is that "for permanently unresponsive patients who are not not otherwise dying, tube feeding should be presumed to be ordinary and proportionate... unless its use would conflict with other grave responsibilities or would be overly burdensome, costly or otherwise complicated". This is not a radical departure from the past! Bro. Daniel believes that the intent of the pope's statement is that the case for withdrawing tubes from patients in a PVS is less than for other cases, such as those with diseases like terminal cancer, where tube feeding "will often result in great burden, no net benefit, and multiple complications". He urges caution when determining that feeding tubes are extraordinary in PVS patients, but does not rule it out. Note also the two conditions listed by the pope: providing nourishment, and alleviation of suffering. Terry Schiavo as not suffering, that much at least was clear.
This may be complicated, but for Catholics to keep talking about murder and death by starvation in the Schiavo case is really too much, and not quite consistent with a sound Catholic reading of the case. There is certainly nothing wrong with people arguing that Schiavo should have been kept alive through feeding tubes, and many here had the best of intentions. But it can also be argued the other way. Richard M. Doerflinger, vice president of the Pro-Life Secretariat of the U.S. Conference of Catholic Bishops was an opponent of ending Schiavo's feeding. But even he recognized that, at least before the pope's allocution, that there was enough of a debate that a Catholic could reasonably choose either position. How is this consistent with the venom directed against people like Fr. Paris, I wonder?
No, this was a tragedy that the Republicans tried to turn into a political issue to benefit them. In the process, they exploited and denigrated Catholic teaching. And a further irony: while governor of Texas, George Bush signed a law that allowed hospitals to discontinue life-sustaining medical care, including feeding tubes, in "futility cases". This was used against 6-month-old Sun Hudson who was taken off his ventilator, his parents' wishes to the contrary notwithstanding. Where was the outrage there, I wonder?
Note that I am not wading into the legal debate about what kind of verbal advance directive Terry Schiavo may nor may not have given her husband. If he lied, and his intention was to be simply to be rid of a burden, then this was gravely wrong.
As a final point, Pope John Paul II himself forswore a feeding tube and other life-sustaining treatments when his time came. He died with great dignity. As a true Christian, he did not believe that life was worth sustaining at all costs.