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HONG Suk Young
(Gyeongsang National University, KOREA)
1. Introduction
Theresa Marie "Terri" Schiavo(December 3, 1963 ? March 31, 2005) was a woman from St. Petersburg, Florida. Schiavo,
then 26, collapsed in her home in 1990 and experienced respiratory and cardiac arrest. Within three years, she was
diagnosed as being in a persistent vegetative state. In 1998, Terri's husband and guardian Michael Schiavo
petitioned the courts to remove her gastric feeding tube. But Terri's parents, Robert and Mary Schindler, opposed
this. The courts found that Terri Schiavo was in a persistent vegetative state and that she should not be kept
alive. In 2003, the matter began to receive Unite States national attention. By March 2005, the legal history
around the Schiavo case included fourteen appeals and numerous motions, petitions, and hearings in the Florida
courts. Despite intervention by the other branches, the courts continued to hold that Schiavo was in a persistent
vegetative state, and would want to cease life support. Her feeding tube was removed a third and final time on
March 18, 2005. She died thirteen days later of dehydration at a Pinellas Park hospice on March 31, 2005, at the
age of 41.
In 2004, Pope John Paul Ⅱ stated that health care providers are morally obligated to provide food and water to
patients in persistent vegetative states. A Vatican cardinal Renato Martino, head of the Pontifical Council for
Justice and Peace, opposed removing the feeding tube keeping Terri Schiavo alive. Cardinal Renato Martino told
Vatican Radio February 24, 2005 that if Michael Schiavo[Terri Schiavo's husband] "legally succeeded in provoking
the death of his wife, this would not only be tragic in itself, but it would be a serious step toward legally
approving euthanasia in the United States." Bishop Elio Sgreccia, president of the Pontifical Academy for Life,
told Vatican Radio March 11, 2005 that withdrawing Schiavo's gastric tube would not be a matter of allowing her to
die, but would "inflict death." Bishop Elio Sgreccia told "Terri Schiavo must be considered a living human person,
…, whose juridical rights must be recognized, respected and defended. The removal of the gastric tube used for
nourishing her cannot be considered an 'extraordinary' measure or a therapeutic measure. It is an essential part of
the way in which Terri Schiavo is nourished and hydrated. As far as we are concerned, denying someone access to
food and water is a cruel way of killing someone. The removal of the gastric feeding tube from this person, in
these conditions, may be considered direct euthanasia. For these reasons we regard as illicit the decision to
remove the gastric feeding tube from Terri Schiavo."
Nowaday, we observed that patients in vegetative state increase more and more due to the development of the
medicine, esp. the life-sustaining treatments. The condition known as 'vegetative state' is one in which the person
is still alive but is permanently unconscious even though the patient gives the outward appearances of being alive.
We also observed a strengthening of the concept of quality of life and a weakening of the concept of sanctity of
life and the strength of solidarity. Added to limitations or lack of sufficient support to families to cover the
costs of prolonged care for patients in vegetative state, this caused a gradually increasing pressure to take off
the burdens. Therefore some argue that life-sustaining medical treatments for patients in vegetative state could be
withheld or withdrawn if the treatments would be burdensome.
The ethical issues around patients in vegetative state is the following: If a patient is competently and securely
diagnosed to be in a vegetative state, does the continuation of life support efforts become ethically optional? Of
special concern is the matter of artificially delivered nutrition and hydration. The relevant criteria for
determining whether artificial feeding of patients is morally required are clear. Such feeding is obligatory unless
it is either useless or excessively burdensome. But applying these criteria to persons said to be in the
"vegetative state" is a matter of serious controversy. Some contend that such feeding is futile and hence not
obligatory. Others maintain that, unless the contrary can be clearly shown, such feeding is neither futile nor
unduly burdensome and is therefore morally obligatory as an ordinary means of preserving life.
In this essay, I try to show that the latter position is correct. I will firstly provide an accurate description of
the vegetative state, secondary summarize the Catholic teaching on prolonging life, lastly provide the arguments
that artificially feeding is morally obligatory unless it can be clearly shown to be futile.
2. What is the Vegetative State?
The vegetative state itself is a form of deep unconsciousness. The upper part of the brain (the cerebral cortex)
gives evidence of impaired or failed operation. Since this part of the brain is neurologically involved in such
activities as understanding, willing, and communicating, patients in vegetative state are not able to engage in
these activities. But the brain stem, which controls involuntary functions such as breathing, blinking, circulating
blood, cycles of waking and sleeping, etc., is still functioning. As a result, patients in vegetative state may
open their eyes and sometimes follow movements with them or respond to loud or sudden noises(although such
responses will not be long sustained nor are they apparently purposeful). It is commonly held that patients in
vegetative state have no consciousness experience and are incapable of experiencing pain, and that it is unlikely
that patients in this state will recover consciousness. However, their condition has stabilized, and they are not
in immediate danger of death so long as they are given appropriate 'food,' and this can be provided them by various
artificial means made possible by modern medical technology. Therefore, Patients in vegetative state are not
comatose. A coma is a state of 'unarousable unresponsiveness' which may last as long as six months but will
inevitably resolve itself into another state.
This is a definition of persistent vegetative state understandable in layman's term: "Condition in which the
patient is awake without being aware. In this state the brain stem is functioning but the cerebral cortex is not,
and the patient lies with his eyes open, looks around, but has no meaningful interaction with the environment." G.
L. Gigli and M. Valente hold that "there is no clinical difference between vegetative state (plain) and persistent
vegetative state and it is actually impossible to predict, on an individual basis, those patients who are
candidates to recovery. For these reason, the use of the term persistent, meant to imply the irreversible nature of
vegetative state, has been discouraged. However, more recently, the term permanent to imply an irreversible state
has been recommended. A patient in vegetative state would be defined permanently vegetative when the diagnosis of
irreversibility is established to a high degree of clinical certainty, that is when the chance of regaining
consciousness becomes extremely unlikely."
Since patients diagnosed as being in the vegetative state are by no means imminently in danger of death and since
their lives can be protected, perhaps for several years, the ethical question in caring for them is whether
providing them with food and nourishment by tubes is morally obligatory or 'ordinary' or whether withholding or
withdrawing food so provided is 'extraordinary'. It is important to note that patients in vegetative state can, in
fact, be fed orally in the beginning. However, those caring for them will usually prefer not to feed them orally
because this is quite time-consuming, particularly if there are other patients for whom they must care. Thus
feeding them by means of tubes is far more convenient. If not fed orally, the ability of patients in this state to
take food orally gradually atrophies
3. The Historical Development of Catholic Teaching on Prolonging life
Catholic teaching on prolonging life has formally evolved over the course of five hundred years, from the
foundational works of certain sixteenth and seventeenth century theologians to recent statements issued by the
moral magisterium of the Catholic Church. The first explicit treatment of what one is obliged to undergo to prolong
life came from the great sixteenth century Spanish Dominican theologian, Franciso De Vitoria(1486-1546). In his
Relectiones Theologiae, Vitoria considers whether one violates the natural law obligation to protect and to
preserve life if one fails to eat certain foods when sick. Vitoria replied: "If a sick man can take food or
nourishment with some hope of life, he is held to take the food, as he would be held to give it to one who is sick.
[However], if the depression of spirit is so low and there is present such consternation in the appetitive power
that only with the greatest of effort and as though by means of a certain torture, can the sick man take food,
right away that is reckoned a certain impossibility, and therefore he is excused, at least from moral sin,
especially where there is little hope of life or none at all." Vitoria also addressed the issue of the use of
medicinal drugs. Here, too, he pointed out that one is not obliged to use every possible means to prolong life:
"One is not held, as I said, to employ all the means to conserve his life, but it is sufficient to employ the means
which are of themselves intended for this purpose and congruent. Wherefore, in the case which has been posited, I
believe that the individual is not held to give his whole inheritance to preserve his life, … From this it is also
inferred that when one is sick without hope of life, granted that a certain precious drug could produce life for
some hours or even days, he would not be held to buy it but it is sufficient to use common remedies, and he is
considered as though dead."
Another Dominican theologian from Spain, Domingo Banez(1528-1604) played an important part in the historical
development of Catholic teaching on prolonging life. He introduced the terms 'ordinary' and 'extraordinary' into
the discussion of morally obligatory and morally optional means of preserving life. Banez remarks: "He is not bound
absolutely speaking. The reason is that, although a man is held to conserve his own life, he is not bound to
extraordinary means but to common food and clothing, to common medicines, to a certain common and ordinary pain;
…."
Subsequent theologians were quick to pick up on the ordinary-extraordinary means distinction articulated by Banez,
and in short time the distinction became firmly established in the Catholic moral tradition. In fact, the
distinction is still operative today, even though some contemporary commentators have challenged its practical
relevance.
In a 1950 article, Gerald Kelly(1902-1964) examined the Catholic tradition on the moral responsibility in
prolonging life decisions and summarized the traditional definitions of ordinary and extraordinary means: "Speaking
of the means of preserving life and of preventing or curing disease, moralists commonly distinguish between
ordinary and extraordinary means. They do not always define these terms, but a careful examination of their words
and examples reveals substantial agreement on the concepts. By ordinary they mean such things as can be obtained
and used without great difficulty. By extraordinary they mean everything which involves excessive difficulty by
reason of physical pain, repugnance, expense, and so forth." In a 1951 article, Kelly proposed the following
modified definitions: "Ordinary means are all medicines, treatments, and operations, which offer a reasonable hope
of benefit and which can be obtained and used without excessive expense, pain, or other inconvenience.
Extraordinary means are all medicines, treatments, and operations, which cannot be obtained and used without
excessive expense, pain, or other inconvenience, or which, if used, would not offer a reasonable hope of benefit.
With these definitions in mind, we could say without qualification that the patient is always obliged to use
ordinary means. On the other hand, insofar as the precept of caring for his health is concerned, he is never
obliged to use extraordinary means."
In an address delivered to an International Congress of Anesthesiologists on 24 November 1957, Pope Pius
?(1876-1958) confirmed the foundational teaching on prolonging life and Kelly's specification of the meaning of
ordinary and extraordinary means. In discussing one's moral obligation to use mechanical ventilation to preserve
life, Pope Pius ? outlined some of the major features of the ordinary-extraordinary means distinction as it had
developed since Vitoria. Pope Pius ? addressed: "Natural reason and Christian morals say that man has the right and
duty in case of serious illness to take the necessary treatment for the preservation of life and health. … But
normally one is held to use only ordinary means -according to circumstances of persons, places, time and culture-
that is to say, means that do not involve any grave burden for oneself or another. A more strict obligation would
be too burdensome for most men and would render the attainment of the higher, more important good too difficult.
Life, health, all temporal activities are in fact subordinated to spiritual ends. On the other hand, one is not
forbidden to take more than the strictly necessary steps to preserve life and health, as long as he does not fail
in some more serious duty." By situating the discussion of the means necessary to prolong life against the backdrop
of one's ultimate end in God, Pope Pius ? specified even more precisely the meaning of ordinary and extraordinary
means. He implies that medical treatment must be evaluated in the light of the patient's overall medical condition
and the patient's ability to pursue spiritual goods. Thus ordinary means are those that are morally obligatory
because they offer a reasonable hope of benefit in helping one to pursue the spiritual goods of life without
imposing an excessive burden; and extraordinary means are those means that are morally optional because they do not
offer a reasonable hope of benefit in terms of helping one to pursue the spiritual goods of life, or because they
impose an excessive burden on one and profoundly frustrate one's pursuit of the spiritual goods of life.
The Congregation for the Doctrine of the Faith provided further confirmation of the traditional teaching on the
moral responsibility in prolonging life in its 1980 Declaration on Euthanasia. Addressing the issue of whether all
possible means must be used to preserve life, the Congregation for the Doctrine of the Faith noted that the means
'ordinary' and 'extraordinary' are less clear today, and that perhaps the terms proportionate and disproportionate
are more accurate. In order to assess the proportionality of means, the Congregation for the Doctrine of the Faith
noted that one should "study the type of treatment to be used, its degree of complexity or risk, its cost and the
possibilities of using it, and [compare] these elements with the result that can be expected," taking into account
one's overall medical condition and physical and moral resources. The Congregation for the Doctrine of the Faith
also remarked that one need make do only with the normal means that medicine can offer, without having recourse to
established medical treatments that carry a risk or disproportionate burden. It made clear that one's refusal of
disproportionate treatment "is not the equivalent of suicide"; rather, "it should be considered as an acceptance of
the human condition," a desire to avoid excessive burdens, or a wish not "to impose excessive expense" on one's
family or the community. It also specified that when death is imminent, one may withhold or withdraw certain forms
of medical treatment that "would only secure a precarious and burdensome prolongation of life". The Declaration on
Euthanasia establishes that Catholic teaching on prolonging life has continued largely unchanged from the time of
Vitoria to today. Introducing the terms 'proportionate' and 'disproportionate' did not significantly change the
traditional teaching.
Two other Catholic reports on the moral responsibility in prolonging life decisions have been advanced by
pontifical agencies. First, the Pontifical Council Cor Unum issued a report in 1981 dealing with the ethical
aspects of providing medical care to person at the end-of-life. Second, the Pontifical Academy of Sciences issued a
report in 1985 dealing with the moral obligation to use life-sustaining medical treatment and the criteria
necessary for determining the exact moment of death. These reports seem to indicate that medically assisted
nutrition and hydration should be considered "ordinary or proportionate" means of prolonging life and thus should
be used unless death is imminent or they impose an excessive burden on the patient. But these reports lack the
authoritative doctrinal status of papal teaching and statements of the Congregations. These reports were actually
made to the pope, but they have not been "officially promulgated by him to date or made part of authoritative
teaching".
4. Providing Food to Patients in Vegetative State Is Obligatory.
Nutrition and hydration should always be provided to all patients, including patients in vegetative state, unless
they cannot be assimilated by a person's body, they do not sustain life, or their only mode of delivery imposes
grave burdens on the patient or others. The consequences of decisions on nutrition and hydration withdrawal is
death of patients in vegetative state. Death by starvation and dehydration "denies the respect we have for the
dying person. Even a dead person is treated with respect and we would not carry out acts on a dead body simply
because they would not be felt." Gigli and Valente maintain that "We believe that, although unintended, the
withdrawal of nutrition and hydration to patients in vegetative state … can actually turn out to be, in the long
term, the Trojan horse to make active euthanasia acceptable to societies and health professionals."
The United States Pennsylvania bishops issued a document dealing with artificially providing food to patients in
vegetative state on January 14, 1992. This document concluded by declaring: "As a general conclusion, in almost
every instance there is an obligation to continue supplying nutrition and hydration to the unconscious patient.
There are situations in which this is not the case [for example, when patient can no longer assimilate the food and
its provision is hence useless], but these are exceptions and should not be made into the rule." In their judgement
artificially providing food to patients in vegetative state is "clearly beneficial in terms of preservation of
life," nor does it, in almost every case, add a "serious burden." Consequently, it is morally obligatory.
On March 24, 1992, the Administrative Committee of the United States Conference of Catholic Bishops[USCCB]
authorized the publication of a substantive document prepared by the Committee for Pro-Life Activities of the
USCCB. This document surveyed, somewhat extensively, relevant medical literature dealing with the issue and
different positions taken by moral theologians. In their view of the theological opinions, the author of this
document explicitly state that they do not find persuasive the rationale of some theologians that since patients in
vegetative state can no longer pursue the spiritual goal of life, feeding them artificially is futile and unduly
burdensome. In the conclusion of their paper, the authors have this to say: "We hold for a presumption in favor of
providing medically assisted nutrition and hydration to patients who need it, which presumption would yield in
cases where such procedure have no medically reasonable hope of sustaining life or pose excessive risks or
burdens."
The view, like that of the Pennsylvania Bishops and the Pro-Life Committee of the United States Conference of
Catholic Bishops, holds that artificially providing food to permanently unconscious persons (patients in vegetative
state) is to be regarded ordinarily as morally obligatory insofar as it is neither useless nor unduly burdensome.
In Directive no. 58 of the Ethical and Religious Directives for Catholic Health Care Services (November 1994), the
bishops of the United States hold that "There should be 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."
Some argue that the expense entailed in feeding patients in vegetative state must realistically be regarded as
terribly burdensome in our society. But, no one, we can presume, would want his family bankrupted in order to
provide patients in vegetative state with tubally assisted feeding. Therefore, the cost for taking care of patients
in vegetative state have to be more and more covered by insurance or other programs. Now we should legitimately
strive to avoid excessive expense without abandoning care for the patients in vegetative state and without bringing
his or her death by starvation and dehydration.
The total cost of caring for patients in vegetative state (providing them with a heated room, nursing care, etc.)
could be quite great, but it would be unfair and unjust to deprive the patients in vegetative state of their fair
share. Germain Grisez develops the truth that another human good served by feeding patients in vegetative state in
this way is the good of human solidarity. In another work Grisez expresses this idea as follows: "life-sustaining
care for severly handicapped does have a human and Christian significance in addition to the one it would derive
precisely from the inherent goodness of their lives. This additional significance is … profoundly real, just as is
the significance …, which continues to benefit not only the person being cared for but the one giving care."
The entire story of withdrawal of nutrition and hydration is a turning point of our civilization, it is
paradigmatic of the direction in which we want to orient our mutual relationships, of the way in which we want to
care for and relate to elderly, handicapped and unconscious people for the years to come. There is the concrete
risk of further weakening the ties of solidarity inside families and inside the social body.
Some moralists profess a certain uneasiness with granting that food and water can ever be regarded as medical
treatment. If we define 'medical treatment' as "an action or group of actions performed to alleviate or neutralize
some sort of pathological condition or disease", the logical question arises: if food and water are medical
treatment, what precisely do they treat? Patients can be weaned from respirators, to be sure, but they cannot be
taken off of nutrition and hydration. Because there is a distinction between tube feeding and other form of
life-sustaining treatments such as ventilation or dialysis. Tube feeding for patients in vegetative state is not a
medical treatment, but a basic care.
5. Conclusion
Patients in vegetative state has been challenged from the ethical point of view, proposing the withdrawal of
assisted nutrition and hydration. However, this ethical point of view can be very dangerous. Patients in vegetative
state is not in fact dying of any fatal pathology. They are simply persons seriously impaired. If removing the tube
feeding, patients in vegetative state will die from starvation and dehydration. In other words, death is the
inevitable consequence of the withdrawal of assisted nutrition and hydration. Obviously, the purpose of removing
the feeding-tube is to hasten a death of patients in vegetative state. Nutrition and hydration is not a form of
medical treatment, which, in analogy to other forms of life-sustaining treatments such as the use of the
respirator, may be discontinued in accordance with the principles and practices governing the withholding and
withdrawal of other forms of medical treatment. Nutrition and hydration is a form of basic ordinary care, which
should always be provided to all patients including patients in vegetative state.
Gigli and Valente criticize the current discussion about quality of life. They maintain as the following: "In our
opinion, the discussion about quality of life often hide a kind of evaluation typical of the interpersonal
relationships in our society, based on the ability to produce and to be useful. In this society, not only the lives
of patients in vegetative state, but also those of gravely disabled patients and of every person marginalized out
of the productive system are considered less worthy." Therefore E. Sgreccia and I. C. de Paula "have made a
positive proposal. The concept of quality of life, which is often used as a pretext for the propagation of
euthanasia and eugenics, has been declared to be positive, on condition, however, that it is considered in the
light of a person in his or her entirety, and with reference to the hierarchy of values within each person and
those of our society. In other words, the quality of life must favour within each person a balance between what is
beneficial at a corporeal, emotional and spiritual level, each aspect being considered as part of the harmony and
hierarchy of values; at the same time, the good of society and the development of the environment must be the
result of the commitment of every individual for the good of all people in the context of justice and of a new and
greater solidarity. Therefore, …; moreover, quality of life can depend only on respect for life and the right to
life, …; it must be a quality which is founded on the inviolability and dignity of each person, where the notion
of dignity and inviolability is extended to include a person's corporeal dimension, which is a fundamental value of
one's own personal existence." Therefore the quality of life of patients in vegetative state must be a quality
which is founded on the inviolability and sanctity of his or her life.
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