Clinical - Ethical Judgements without "short cuts"

Pope John Paul II's address to the recent conference on life-sustaining treatments and the 'vegetative state' brings further clarification to a long running debate among Catholic ethicists about our obligations towards persistently unresponsive patients. [1] All participants in this debate agree that there is an obligation to take reasonable (or "ordinary") means of sustaining a person's life, unless and until doing so becomes "futile" or "unduly burdensome" (i.e. "extraordinary"). The debate has centred on the application of this principle to unresponsive patients.

With respect to the principle itself, one of the most impressive contributions at the conference was from Maurizio Calipari, a bioethicist with the Pontifical Academy for Life. [2] Reviewing the traditional teaching of the Church and of Catholic moralists, he argued that the tradition understands a treatment to be ordinary and obligatory unless there is reason in a particular case for it to be judged extraordinary (and so not obligatory). The terms "ordinary" and "extraordinary" have, of course, become ambiguous in recent years, since they are often taken to measure simply the "ordinariness" of a treatment in medical practice; thus treatments once extraordinary (in a numerical or financial sense) may now be quite ordinary, cost effective, and in common use. For purposes of ethical analysis alternative terms have been suggested, e.g. "proportionate" and "disproportionate".

Calipari proposes that these sets of terms be distinguished and applied to two distinct steps in a clinical-ethical analysis. The first issue concerns the appropriateness of a treatment from the medical point of view. A treatment is "proportionate" to the extent that it is suitable for achieving an appropriate medical goal in the circumstances. The second issue concerns the appropriateness of a treatment for this particular patient. At this point, the issue is whether a proportionate treatment would be "ordinary" or "extraordinary": would it involve a certain "impossibility" for the patient, because it would impose an undue burden on the patient or on carers or health care resources?

Returning to the debate among Catholic ethicists, Calipari's analysis enables us to identify what I will call two "short cuts" in clinical-ethical reasoning that are commonly deployed in this debate. While accepting the obligation to use ordinary life-sustaining means, some Catholic ethicists have argued that persistently unresponsive patients (those said to be in a "vegetative state") constitute a special category of patients. Given their lack of responsiveness and the unlikelihood of any improvement, it has been argued that no legitimate medical benefit arises simply from keeping these patients alive. (A few ethicists have gone further and argued that to prolong the life of such patients is contrary to their dignity; they claim these patients are dying and should be allowed to die.) This approach involves the first "short cut" - namely, to suppose that the unresponsive state of itself alters the kind of obligation there is to preserve a person's life, or to suppose that the normal medical goal of sustaining life no longer holds for these patients.

Of course, if persistently unresponsive patients are to be kept alive, they need to be given food and water by other people, and typically, by tubes inserted through the nose or directly into the stomach. Where tubes are used, the patients are said to be receiving nutrition and hydration by "artificial means". Some Catholic ethicists have argued that the need to use tubes, given the medical expertise required to insert the tubes and supervise their use, shows that such feeding is "extraordinary", and is disproportionate to the proposed benefit. The Supreme Court in Victoria in 2003 adopted this view when it held that tube-feeding was indeed a "medical treatment", and as such was optional, able to be withheld or withdrawn at the guardian's request. This approach involves a second "short cut" - namely, to suppose that because a procedure is, or involves, a medical treatment it is not an ordinary and so obligatory means of sustaining life.

The Pope's address can be summarised as rejecting both these "short cuts". First, the Pope says that persistently unresponsive patients are not a special class of persons for whom the normal medical goals and obligations do not apply. They are human persons, with the same rights as others, albeit they are severely disabled. Although they are unresponsive, these patients are not as such dying. Their situation is not like that of patients who are close to death (in a few days or hours), irrespective of what care or feeding is offered to them. So to say that unresponsive patients need not (or should not) be fed amounts to saying it would be better if they died. To stop feeding an unresponsive person for this reason would be equivalent to euthanasia.

Secondly, the Pope says that "artificial" feeding through tubes is not in itself an "extraordinary" means of sustaining life. On the contrary, feeding a person is a "natural" means of caring for him or her, and, in the context of modern medicine, the use of tubes can be a convenient and cost effective way of feeding a person. Tube feeding is "in principle, [an] ordinary and proportionate, and as such morally obligatory", way of caring for a patient.

If we avoid the two "short cuts" I have noted, and following Calipari's analysis, we see there are two sets of questions we need to ask about tube feeding: first, is it proportionate or effective? Is it keeping the person alive? If it is not, e.g. because the patient cannot absorb the nutrition, then it should be stopped. Secondly, is it extraordinary for this patient? Does it involve burdens to the patient which outweigh its benefits? If it does, e.g. because of infections and problems in maintaining the tube in place, then it may be stopped.

The key sentences in the pope's address are: "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 in which and as long as it is seen to achieve its proper purpose which in the present case consists in providing nourishment to the patient and alleviation of his suffering."

An issue the Pope does not address specifically is whether, even if the act of feeding a patient is "ordinary" and "natural", the insertion of a feeding tube is in itself a "medical act". I think it is clear that the insertion and monitoring of a tube, and of the substances and quantities inserted, does involve medical and nursing expertise. To this extent, it is a medical procedure that needs to be judged by the usual clinical and ethical criteria. The degree of medical intervention that tube feeding requires in a particular case needs to be proportionate to the prospective benefit, and not unduly burdensome. In making this judgment, it is important to recall that keeping a patient alive, even an unresponsive patient, is always in principle a legitimate and obligatory medical goal.

Conclusion

I have said that the pope's address warns us against two "short cuts" in ethical reasoning. There should be a presumption, in principle, that all patients be given food and water (if necessary through tubes) unless and until this is disproportionate (not effective) and/or extraordinary (unduly burdensome). Each case must therefore be examined on its own merits - there should be no short cuts that save us from examining the facts in each case. In particular cases it may be apparent that tube feeding is not obligatory: e.g. in contexts such as the developing world where there is no medical expertise available to insert and monitor the tube; or where the tube is causing infection and other disproportionate side-effects, thereby adding to the patient's complications; or where the patient cannot absorb the food etc.

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[1] I use the term 'vegetative state' because that is the term used in the papal statement.

[2] Calipari's paper is available in the special edition of L'arco di Giano, published for the conference by Instituto per 1'Analisi dello Stato Sociale, (March, 2004), pp. 50-57.

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Rev Dr Gerald Gleeson is a moral theologian and priest of the Archdiocese of Sydney. He lectures at the Catholic Institute of Sydney and is a research associate at the Plunkett Centre for Ethics and Health Care (Australian Catholic University/St. Vincent's Hospital).

The Nathaniel Centre is grateful to the author and the Plunkett Centre for Ethics (Sydney) for permission to reproduce this article.