Implications of the Papal Allocution on Feeding Tubes

The recent papal allocution To the International Congress on Life-Sustaining Treatment and Vegetative State." Scientific Advances and Ethical Dilemmas has been the occasion for much discussion concerning the use of artificial feeding tubes for nutrition and hydration. Briefly, the Pope stated in the March address that such tubes were "not a medical act" and that their use "always represents a natural means of preserving life" and is part of "normal care." Therefore, their use is to be morally evaluated as ordinary and obligatory. "If done knowingly and willingly," the removal of such feeding tubes is "euthanasia by omission." The person's medical condition is not relevant in making a determination about the use of feeding tubes because the food and water delivered through such tubes is ordinary care and provides a benefit--"nourishment to the patient and alleviation of his suffering." (1) What is interesting about this papal allocution is that it seems to represent a significant departure from the Roman Catholic bioethical tradition with respect to both the method and the basis upon which such decisions are made. The method announced by Pope John Paul II seems to be deontological. The use of feeding tubes to deliver artificial nutrition and hydration is declared "ordinary," and such an intervention apparently ought not be forgone or withdrawn. Historically, the method for making a determination about the use of a medical intervention was to consider the proportional benefits and its harms to the individual, family, and community. The method is a teleological balancing of the impact of the intervention. This has been the central teaching of the tradition from the mid-1600s through Pope Plus XII and the 1987 Declaration on Euthanasia by the Congregation for the Doctrine of the Faith. (2) The examples of disproportionately harmful impacts in the Roman Catholic tradition range from the use of expensive medications, food beyond the budget of the individual, and interventions that are painful in both the short and long term, to the refusal of a physical examination if that will cause excessive embarrassment to the individual. Included in such a listing and specifically noted in the Declaration on Euthanasia is the financial impact on both the patient and family. Interventions that will provide a significant financial hardship need not be utilized. The question of the use of artificial feeding tubes has been much debated in Roman Catholic bioethics, especially when used for patients in persistent vegetative state. (3) One early statement was from the revered Jesuit moral theologian Gerald Kelly: I see no reason why even the most delicate professional standard should call for their [oxygen and intravenous nutrition and hydration for a patient in a terminal coma] use. In fact, it seems to me that, apart from very special circumstances, the artificial means not only need not but also should not be used, once the coma is reasonably diagnosed as terminal. Their use creates expense and nervous strain without conferring any real benefit. (4) There were further arguments made on both sides of the issue by theologians, bishops, and bishop conferences. Over time a consensus seemed to develop that the forgoing or withdrawal of artificial feeding tubes could be judged morally optional in some circumstances. The reason the papal statement is so startling to many is that it came out of the blue. It seems to depart from the tradition of Roman Catholic bioethics on how to analyze such questions and substitutes a deontological principle for the traditional weighing of benefits to burdens. Thus it raises a number of very practical questions for patients, theologians, medical personnel, and Catholic hospital administrators. One question concerns the authority of the statement. Traditionally, allocutions are given to a variety of groups that meet in Rome, but they have not always been seen as the locus for announcing a major policy shift. …