CONGREGATION FOR THE DOCTRINE OF THE FAITH
RESPONSES TO CERTAIN QUESTIONS
OF THE UNITED STATES CONFERENCE OF CATHOLIC BISHOPS
CONCERNING ARTIFICIAL NUTRITION
AND
HYDRATION
First question: Is the administration of food
and water (whether by natural or artificial means) to a patient in a "vegetative
state" morally obligatory except when they cannot be assimilated by the
patient’s body or cannot be administered to the patient without causing
significant physical discomfort?
Response: Yes. 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.
Second question: When nutrition and hydration
are being supplied by artificial means to a patient in a "permanent vegetative
state", may they be discontinued when competent physicians judge with moral
certainty that the patient will never recover consciousness?
Response: No. A patient in a "permanent
vegetative state" is a person with fundamental human dignity and must,
therefore, receive ordinary and proportionate care which includes, in principle,
the administration of water and food even by artificial means.
* * *
The Supreme Pontiff Benedict XVI, at the Audience granted to
the undersigned Cardinal Prefect of the Congregation for the Doctrine of the
Faith, approved these Responses, adopted in the Ordinary Session of the
Congregation, and ordered their publication.
Rome
, from the
Offices of the Congregation for the Doctrine of the Faith,
August 1, 2007
.
COMMENTARY from the Congregation for the Doctrine of
the Faith
The Congregation for the Doctrine of the Faith has formulated
responses to questions presented by His Excellency the Most Reverend William S.
Skylstad, President of the United States Conference of Catholic Bishops, in a
letter of
July 11, 2005
, regarding
the nutrition and hydration of patients in the condition commonly called a
"vegetative state". The object of the questions was whether the nutrition and
hydration of such patients, especially if provided by artificial means, would
constitute an excessively heavy burden for the patients, for their relatives, or
for the health-care system, to the point where it could be considered, also in
the light of the moral teaching of the Church, a means that is extraordinary or
disproportionate and therefore not morally obligatory.
The Address of Pope Pius XII to a Congress on
Anesthesiology, given on
November 24, 19
57
,
is often invoked in favor of the possibility of abandoning the nutrition and
hydration of such patients. In this address, the Pope restated two general
ethical principles. On the one hand, natural reason and Christian morality teach
that, in the case of a grave illness, the patient and those caring for him or
her have the right and the duty to provide the care necessary to preserve health
and life. On the other hand, this duty in general includes only the use of those
means which, considering all the circumstances, are ordinary, that is to say,
which do not impose an extraordinary burden on the patient or on others. A more
severe obligation would be too burdensome for the majority of persons and would
make it too difficult to attain more important goods. Life, health and all
temporal activities are subordinate to spiritual ends. Naturally, one is not
forbidden to do more than is strictly obligatory to preserve life and health, on
condition that one does not neglect more important duties.
One should note, first of all, that the answers given by Pius
XII referred to the use and interruption of techniques of resuscitation.
However, the case in question has nothing to do with such techniques. Patients
in a "vegetative state" breathe spontaneously, digest food naturally, carry on
other metabolic functions, and are in a stable situation. But they are not able
to feed themselves. If they are not provided artificially with food and liquids,
they will die, and the cause of their death will be neither an illness nor the
"vegetative state" itself, but solely starvation and dehydration. At the same
time, the artificial administration of water and food generally does not impose
a heavy burden either on the patient or on his or her relatives. It does not
involve excessive expense; it is within the capacity of an average health-care
system, does not of itself require hospitalization, and is proportionate to
accomplishing its purpose, which is to keep the patient from dying of starvation
and dehydration. It is not, nor is it meant to be, a treatment that cures the
patient, but is rather ordinary care aimed at the preservation of life.
What may become a notable burden is when the "vegetative
state" of a family member is prolonged over time. It is a burden like that of
caring for a quadriplegic, someone with serious mental illness, with advanced
Alzheimer’s disease, and so on. Such persons need continuous assistance for
months or even for years. But the principle formulated by Pius XII cannot, for
obvious reasons, be interpreted as meaning that in such cases those patients,
whose ordinary care imposes a real burden on their families, may licitly be left
to take care of themselves and thus abandoned to die. This is not the sense in
which Pius XII spoke of extraordinary means.
Everything leads to the conclusion that the first part of the
principle enunciated by Pius XII should be applied to patients in a "vegetative
state": in the case of a serious illness, there is the right and the duty to
provide the care necessary for preserving health and life. The development of
the teaching of the Church’s Magisterium, which has closely followed the
progress of medicine and the questions which this has raised, fully confirms
this conclusion.
The Declaration on Euthanasia, published by the Congregation
for the Doctrine of the Faith on
May 5, 1980
, explained the distinction between proportionate and
disproportionate means, and between therapeutic treatments and the normal care
due to the sick person: "When inevitable death is imminent in spite of the means
used, it is permitted in conscience to take the decision to refuse forms of
treatment that would only secure a precarious and burdensome prolongation of
life, so long as the normal care due to the sick person in similar cases is not
interrupted" (Part IV). Still less can one interrupt the ordinary means of care
for patients who are not facing an imminent death, as is generally the case of
those in a "vegetative state"; for these people, it would be precisely the
interruption of the ordinary means of care which would be the cause of their
death.
On
June
27, 1981
, the Pontifical Council Cor Unum published a document
entitled Some Ethical Questions Relating to the Gravely Ill and the Dying, in
which, among other things, it is stated that "There remains the strict
obligation to administer at all costs those means which are called ‘minimal’:
that is, those that normally and in usual conditions are aimed at maintaining
life (nourishment, blood transfusions, injections, etc.). The discontinuation of
these minimal measures would mean in effect willing the end of the patient’s
life" (no. 2.4.4.).
In an Address to participants in an international course on
forms of human preleukemia on
November 15, 1985
, Pope John Paul II, recalling the Declaration on
Euthanasia, stated clearly that, in virtue of the principle of proportionate
care, one may not relinquish "the commitment to valid treatment for sustaining
life nor assistance with the normal means of preserving life", which certainly
includes the administration of food and liquids. The Pope also noted that those
omissions are not licit which are aimed "at shortening life in order to spare
the patient or his family from suffering".
In 1995 the Pontifical Council for Pastoral Assistance to
Health Care Workers published the Charter for Health Care Workers, paragraph 120
of which explicitly affirms: "The administration of food and liquids, even
artificially, is part of the normal treatment always due to the patient when
this is not burdensome for him or her; their undue interruption can have the
meaning of real and true euthanasia".
The Address of John Paul II to a group of Bishops from the
United States of America
on a visit ad limina,
on
October 2, 1998
,
is quite explicit: nutrition and hydration are to be considered as normal care
and ordinary means for the preservation of life. It is not acceptable to
interrupt them or to withhold them, if from that decision the death of the
patient will follow. This would be euthanasia by omission (cf. no. 4).
In his Address of
March 20, 2004
, to the participants of an International Congress on
"Life-sustaining Treatments and the
Vegetative
State
:
scientific progress and ethical dilemmas", John Paul II confirmed in very clear
terms what had been said in the documents cited above, clarifying also their
correct interpretation. The Pope stressed the following points:
1) "The term permanent vegetative state has been coined to
indicate the condition of those patients whose ‘vegetative state’ continues for
over a year. Actually, there is no different diagnosis that corresponds to such
a definition, but only a conventional prognostic judgment, relative to the fact
that the recovery of patients, statistically speaking, is ever more difficult as
the condition of vegetative state is prolonged in time" (no. 2).1
2) In response to those who doubt the "human quality" of
patients in a "permanent vegetative state", it is necessary to reaffirm that
"the intrinsic value and personal dignity of every human being do not change, no
matter what the concrete circumstances of his or her life. A man, even if
seriously ill or disabled in the exercise of his highest functions, is and
always will be a man, and he will never become a ‘vegetable’ or an ‘animal’"
(no. 3).
3) "The sick person in a vegetative state, awaiting recovery
or a natural end, still has the right to basic health care (nutrition,
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 possible 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, to the extent to which, and for as long as, it is shown to
accomplish its proper finality, which in the present case consists in providing
nourishment to the patient and alleviation of his suffering" (no. 4).
4) The preceding documents were taken up and interpreted in
this way: "The obligation to provide the ‘normal care due to the sick in such
cases’ (Congregation for the Doctrine of the Faith, Declaration on Euthanasia,
p. IV) includes, in fact, the use of nutrition and hydration (cf. Pontifical
Council Cor Unum, Some Ethical Questions Relating to the Gravely Ill and the
Dying, no. 2, 4, 4; Pontifical Council for Pastoral Assistance to Health Care
Workers, Charter for Health Care Workers, no. 120). The evaluation of
probabilities, founded on waning hopes for recovery when the vegetative state is
prolonged beyond a year, cannot ethically justify the cessation or interruption
of minimal care for the patient, including nutrition and hydration. Death by
starvation or dehydration is, in fact, the only possible outcome as a result of
their withdrawal. In this sense it ends up becoming, if done knowingly and
willingly, true and proper euthanasia by omission" (n. 4).
Therefore, the Responses now given by the Congregation for the
Doctrine of the Faith continue the direction of the documents of the Holy See
cited above, and in particular the Address of John Paul II of
March 20, 2004
. The basic points are two. It is
stated, first of all, that the provision of water and food, even by artificial
means, is in principle an ordinary and proportionate means of preserving life
for patients in a "vegetative state": "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". It is made clear,
secondly, that this ordinary means of sustaining life is to be provided also to
those in a "permanent vegetative state", since these are persons with their
fundamental human dignity.
When stating that the administration of food and water is
morally obligatory in principle, the Congregation for the Doctrine of the Faith
does not exclude the possibility that, in very remote places or in situations of
extreme poverty, the artificial provision of food and water may be physically
impossible, and then ad impossibilia nemo tenetur. However, the obligation to
offer the minimal treatments that are available remains in place, as well as
that of obtaining, if possible, the means necessary for an adequate support of
life. Nor is the possibility excluded that, due to emerging complications, a
patient may be unable to assimilate food and liquids, so that their provision
becomes altogether useless. Finally, the possibility is not absolutely excluded
that, in some rare cases, artificial nourishment and hydration may be
excessively burdensome for the patient or may cause significant physical
discomfort, for example resulting from complications in the use of the means
employed.
These exceptional cases, however, take nothing away from the
general ethical criterion, according to which the provision of water and food,
even by artificial means, always represents a natural means for preserving life,
and is not a therapeutic treatment. Its use should therefore be considered
ordinary and proportionate, even when the "vegetative state" is prolonged.
_______________________________
1 Terminology concerning the different phases and forms of the
"vegetative state" continues to be discussed, but this is not important for the
moral judgement involved.
[01269-02.02] [Original text: English]
September 14, 2007: Fr. Pavone Welcomes Vatican Statement on Nutrition and Hydration
