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Pro-Life Suites: A response to two articles on ANH--Updated (below the fold)

A couple of weeks ago or so someone on Facebook recommended two articles on the subject of denying artificial nutrition and hydration. (He being on the other side of this issue.) I've been waiting ever since then, after reading the articles, to finish up a bunch of other projects so that I could devote some time to discussing them.

I'm sorry to have to say that these two articles come from an evangelical Christian bio-ethics think-tank, the Center for Bioethics and Human Dignity.

The first piece, by Scott Rae, has the hopeful title "How Much Brain Do I Need to be Human" and is occupied for much of its space with a welcome denial of the central tenet of personhood theory--that severely mentally disabled people are not persons at all. To his credit, Rae expressly rejects the horrifying views of other ostensibly evangelical writers he cites, Robert Wennberg and Robert V. Rakestraw, who argue that a person in a PVS has lost the image of God or that the "person" is dead even if the body is alive. Rae's rejection of these disgusting views is appropriate and, if I may put it this way, disarming. I say “disarming,” because in the midst of affirming the full personhood and even the right to life (!) of people diagnosed as in a PVS and of anencephalic infants and people in the late stages of Alzheimer's, Rae suddenly begins declaring, without conspicuous argument, the legitimacy of withholding nutrition and hydration from such people.

Rae’s only attempt at argument (if it is intended as an argument) is a blanket appeal to authority:

There is a growing consensus, reflected in the Cruzan decision, that medically provided nutrition and hydration are indeed forms of treatment that can be refused, if there is clear evidence that it is the patient’s wish.

Of course, since infants are one of the groups of people in question, the tip of the hat to the doctrine of consent seems like a fifth wheel, especially since at no time in the article does Rae say that it is illegitimate to withhold nutrition and hydration from someone if there is not "clear evidence that it is the patient's wish."

On the contrary--he has some pretty negative implications to make about those who wish to administer ANH to the severely neurologically compromised. And most unfortunately, those negative implications come in the form of a jolting introduction of theology into the discussion.

In most cases feeding tubes are analogous to ventilator support; removal of feeding tubes is not starving a person any more than removing ventilator support is suffocating them. Further, to insist on a mandatory aggressive treatment based on the sanctity of life doctrine is to elevate earthly life to the status of the ultimate good. If the sanctity of life obligates us to do everything at all times to keep people alive, then we are making a dangerous theological assumption about earthly life being the highest good. From a Christian view of the world, earthly life is a penultimate good; the ultimate good being our eternal fellowship with God. Moreover, with death being a conquered enemy, one thing that follows is that death need not always be resisted. It is acceptable to say “enough,” including the removal of feeding tubes.

The first sentence is the barest assertion. The fact that we do not usually have to give people, even helpless and sick people, air at all (air being all around us and being drawn in by the basic, automatic functioning of the body), but that helpless or weak people frequently have to be fed (infants with breast, bottle, or spoon, weakened or very elderly people with spoons, feeding tubes, etc.) even when their basic bodily functions are operating quite well, is not considered at all as a possible counter to the analogy. Rae does not even touch on the ordinary vs. extraordinary care distinction.

But the theological material is worse than just weak on argument. It is actually rather offensive. If giving food and fluids is simply care, ordinary nursing care, rather than "aggressive treatment," as Rae implausibly calls it, what the deuce does all this business about how earthly life is not the ultimate good have to do with anything? If a mother were to leave her newborn infant without a bottle until he died, no jury in the world would take it as a defense that the mother, as a Christian, considered the child's "eternal fellowship with God" to be the ultimate good and considered death to be a "conquered enemy." In fact, such a defense would quite rightly be an embarrassment to Christians. Neglecting a helpless person until he dies cannot be defended on the grounds that earthly life is not the ultimate good. Hence, Rae cannot evade in this way the question of whether leaving a helpless person to dehydrate to death constitutes neglect. This sudden argument from eternity is a fairly transparent attempt to dodge the question of the ordinariness of food and fluids, a vault into theological language in an attempt, in lieu of an argument, to make a theological accusation against people like the Schindlers. What's the matter with you guys? Why do you want Terri to keep receiving food and water through a tube? Don't you get it that death is a conquered enemy? Don't you understand that earthly life is not the ultimate good? This is rather disturbing stuff, and certainly not impressive from an argumentative point of view.

Well, okay, but one piece can't do everything, and in the last few paragraphs Rae returns to his laudable task of affirming the full humanity and personhood of disabled people. (Though even there, and oddly, he says that we need not do everything to treat persons and adds "especially those in a PVS." Why "especially"?) But perhaps the other one, by John T. Dunlop, will make the argument for denial of food and fluids better or more clearly.

Not really. Dunlop certainly addresses a much wider range of cases than does Rae and at least brings up the ordinary vs. extraordinary distinction, but only to drop it the next moment. His article is not very well organized, and some of his statements seem to be in tension with one another, to put it mildly.

He begins by taking "clinicians" to be an authority. At least, that is the best reading I can give to this:

Most clinicians would recommend tube feeding when there is a reversible process that temporarily prevents oral feeding, such as after esophageal surgery. Similarly, there are very few who would recommend tube feeding when the patient cannot eat because of an esophageal blockage caused by an untreatable cancer. This spectrum of conditions forces the question of where to draw the line.

Okay, so if someone has an esophageal blockage caused by untreatable cancer, we're supposed to let him dehydrate to death, even if it's going to take the full two weeks, even if he is not dying imminently of the cancer otherwise, even if he is fully able to assimilate food and fluids. Just because the throat's blocked by cancer, we should do nothing. And that's the conservative position. That's the extreme case where nobody in his senses would have any doubts about the propriety of denying food and fluids. We're just deciding where to "draw the line" between that and a mere short-term feeding tube during surgery recovery. Check.

I hate to say it, but this isn't a very promising start. Next, Dunlop moves to "benefits vs. burdens" of feeding tubes. Well, the benefit, so long as the patient can absorb and use food and fluids is, you know, that you don't die of dehydration over a period of 10-14 days, just like anybody would who was left helpless without food and fluids. Dunlop doesn't exactly put it that way, but he has to acknowledge that the benefit is that it "may allow life to be prolonged for decades in an otherwise healthy individual." He also says that "for some, starvation and dehydration are rather uncomfortable and provision of food and fluids contribute to comfort." Why does this have a strangely understated sound?

He then mentions that feeding tubes are "relatively easy" but considers this benefit something to be mentioned only "in a perverse sense." In other words, he feels uncomfortable about mentioning the ease of tube feeding, because he takes it that using a feeding tube for this reason implies laziness or unwillingness to engage in more personal care. In fact, he even implies that one should resist tube feeding because,

Some of these dear souls are relatively cut off from human touch and care. The only caring they may receive is at meal time. They should not be deprived of this for the convenience of a feeding tube.

This criticism, placed no less in the "benefits" section (!) proceeds, I'm afraid, from a certain amount of ignorance. Case in point: I have personal friends whose Down's Syndrome child eats by mouth but is unable to get enough calories in that way. They provide tube feeding during his sleep at night so that he does not starve to death. Moreover, those who care for weakened people who must receive all their feeding by hand or by tube know that it can be extremely difficult to provide what the patient needs in the way of calories and hydration entirely by spoon feeding, especially if one is being careful not to hurry in order to avoid giving too much at once and choking the patient. To put it bluntly, it's possible to give a baby all he needs by hand with a bottle, because he's just a baby and doesn't need nearly as much in a day as an adult needs. Tube feeding for the sake of ease of adequate feeding is just good sense and need have nothing to do with a desire to deprive a "dear soul" of personal contact. Nor need the two be mutually exclusive. It's probably quite a good idea for people who can eat by mouth to have spoon feeding as well as tube feeding so as to prevent the atrophy of the throat muscles and also, yes, as a form of personal interaction. But to make such personal interaction an argument against tube feeding is just misguided and may proceed from misinformation.

Dunlop then moves on to the burdens of feeding tubes, which include most notably the possibility of aspiration with an NG tube and the possibility of infection at the insertion site of a PEG tube. Dunlop does not mention or perhaps does not know that the danger of aspiration is more often a concern raised about feeding by mouth than about tube feeding and therefore is by no means unique to tube feeding. The danger of aspiration arises from the patient's weakened, semi-conscious, or unconscious state and from the very difficulty swallowing and feeding himself that gave rise to the need for him to be actively fed in the first place. Hence, aspiration worries are, if anything, a "burden" for feeding a weakened and helpless person naturally, and if this "burden" is allowed to bear much weight, would argue for not feeding at all those who most need our help with feeding. Indeed, aspiration is even a concern with bottle feeding for sleepy newborns and preemies, and mothers learn skills by experience that help them to be careful about it. So in the grand scheme, this is not something special about tube feeding and is indeed scarcely worth bringing up. The infection issue is something that requires watchfulness on the part of caregivers, but that is what nursing care is all about. In comparison to leaving a person without food and fluids until he dies, this is quite minor stuff.

Dunlop then makes the following rather surprising statement:

In considering burden we must realize that many people who die without a feeding tube lapse into coma fairly quickly and are unaware of any physical discomfort. Many are not conscious of hunger or thirst.

Really? How many? Are we talking here about people who weren't going to lapse into a coma anyway for some other reason? Are we talking about people who are not dying within the space of days (less than it would take to die of dehydration) of some other cause? Why do they lapse into a coma? You mean just from not receiving food and fluids they lapse into a coma before becoming aware of physical discomfort? This seems highly dubious. As far as I have been able to ascertain, mere dehydration does not produce coma prior to "being aware of any physical discomfort."

On the contrary, there is plenty of evidence that people dehydrated to death experience lots of pain and do not peacefully "lapse into a coma" rather than suffering discomfort. The "peaceful, painless death" story about death by dehydration for people whose bodies are not already actively rejecting food and fluids has been amply refuted, but Dunlop shows no awareness of this evidence. See here and (partially but not entirely overlapping) here. Even Dr. Cranford, an advocate of dehydration for the minimally conscious Robert Wendland, testified in court that Wendland would need a great deal of pain medication if Cranford’s recommendation of death were carried out. Cranford admitted that Wendland might, in fact, have to be put into a coma to escape the pain of dehydration.

In one of the apparent contradictions in the article, Dunlop himself appears to admit problems with this idea that death by dehydration is painless:

What discomfort there is can readily be handled by techniques to moisten the mouth and by using appropriate amounts of analgesics, such as morphine, administered under the tongue.

So we're talking about first causing a person so much discomfort from dehydration that he needs heavy-duty pain-killers like morphine (that sounds like a lot of discomfort to me) and then just administering morphine to take care of it. (Even the doctors who did not admit that Terri Schiavo was conscious put her on a morphine drip during her last days.)

Then we get these two paragraphs:

When the underlying cause of the inability to swallow is thought to be reversible, the feeding tube is used as a treatment. At some times the problem will be caused by surgery or by a stroke and recovery is expected. At other times it may simply be an expression of the patient’s weakness. In that scenario, a key way to gain strength is to provide adequate nutrition. There will be times, however, when a feeding tube intended to be treatment proves ineffective. By default it becomes an intervention to prolong life or to delay death.

Anticipating that situation, it may be wise at the time of insertion to put a time limit on it. For example, Grandma had a major stroke at 97, she is too weak to swallow, and without a feeding tube she will only get weaker. She has often said that she does not want to die “hooked to a machine.” Nevertheless, it may be appropriate to insert a feeding tube, hoping that perhaps within three months she will be stronger and able to swallow on her own. In three months, if she is not able to do that, we want to honor her wishes and discontinue the feeding tube.

So, if the person doesn't get strong enough to eat on his own, the feeding tube was "ineffective" as "treatment." Contrary to common sense, Dunlop does not regard the purpose of the tube as providing food and water, which we all need and which the patient needs. No, its purpose was to enable the patient to get "more better," as children sometimes say--to get well enough to eat and swallow on his own. If it doesn't do that, then it has failed and becomes that invidious thing, an "intervention to prolong life or to delay death."

Let's look at the case of Grandma as Dunlop describes it. In actuality, stroke patients can be fully conscious and are therefore among those who can easily suffer greatly when nutrition and hydration are withdrawn. On the old blog Right Reason I posted an account (no longer on line) given to me anonymously by a lawyer of one of her clients who had a stroke and repeatedly wrote the word "water" on a piece of paper. But the relatives did not want to send her to a nursing home, so she was left without the water she asked for and dehydrated to death. The case of Marjorie Nighbert, discussed by Wesley J. Smith in the Human Life Review article I linked above, is similar. Kate Adamson has testified to her intense pain when she was partially dehydrated after a stroke, though she was saved in the end. I have known of a friend of my own who suffered similarly, though I had no standing to do anything about the matter. So Grandma in Dunlop's scenario is hardly a good example for the case he wants to make of that peaceful slipping away into a coma without experiencing any discomfort. Nor is it clear that a statement that one "does not want to die hooked up to a machine" indicates a conscious, much less an informed, consent to be dehydrated to death rather than have a feeding tube.

In the next paragraph, Dunlop appears to contradict what he has just said about Grandma:

If the feeding tube is used in a patient who has a progressive terminal illness the tube may only delay death and the use of a feeding tube may simply prolong or increase the agony. The operative words are “progressive terminal illness,” which would include such conditions as cancer; kidney, heart, or lung failure. It would also include dementia and advanced age. It does not include someone who is stable though disabled after a brain injury or stroke. In the context of progressive terminal illness it can be argued that tube feeding should generally not be done. When the patient dies the ultimate cause of death is the underlying disease, not starvation or dehydration. [Emphasis added]

But wasn't Grandma "stable though disabled" after a stroke? Dunlop only said that she would get weaker if the feeding tube were withdrawn. Who wouldn't? So there is an apparent inconsistency here.

Let's look at his category of "progressive terminal illness." Dementia and advanced age are progressive, terminal illnesses? Isn't that questionable? By this logic, it would seem that 97-year-old Grandma can legitimately be deprived of food and fluids even if she doesn't have a stroke and is able to swallow--if, perhaps, she is merely unable anymore to sit up and safely feed herself. After all, she suffers from the progressive, terminal illness of advanced age. No doubt, Dunlop did not mean this, but his list is extremely faulty with the inclusion of those two conditions. Even in the case of cancer, the fact that the person has cancer does not mean that the person is imminently dying of cancer. People, of course, live with cancer for years.

Dunlop's airy claim that anyone who has any of these conditions, is denied tube feeding and hydration, and dies, dies of the underlying condition seems much too quick. It seems rather that the question of what the person dies of is best determined by how he is expected to die. If a person with dementia requires tube feeding, is not given it, and dies over the standard dehydration period of ten to fourteen days with progressive symptoms of dehydration, then he dies of dehydration, not of old age and certainly not of dementia. If that is the expected course of death, then whether we admit this to ourselves or not, we are contemplating dehydrating him to death rather than his dying of his "underlying condition."

Now Dunlop moves on to cases where there is not even what he calls a progressive, terminal illness.

In the absence of a progressive terminal disease, the feeding tube may be used to prolong life. Since the patient is not dying of another cause, discontinuing the feeding tube would imply a desire to cause the patient’s death. It is in this context that most of the controversy occurs.

If the patient is able to express her views now, or in the past has clearly expressed her desires on this issue, they should be heeded. All too frequently, however, a statement is made in very categorical terms whether or not to use a feeding tube. It would be wiser, rather than saying yes or no, to discuss the context in which they would not want a feeding tube and allow for situations where they would be willing to have one.[Emphasis added]

What becomes evident on reading these paragraphs is that Dunlop is not willing to say that it is wrong to withhold ANH even when the patient is not on anyone's definition, even his very liberal one, dying of some other cause. Even when, by his own admission, the refusal of nutrition and hydration would cause the death and would "imply a desire to cause the patient’s death," Dunlop is unwilling to make a clear statement. Heaven forbid we should be categorical even about causing people's deaths by withholding food and fluids.

Dunlop makes a similar nod to consent here that Rae does, but unlike Rae, Dunlop does at least go on to discuss situations where the patient does not have views or has not expressed them. (This would, of course, include the case of infants and of people who have been severely cognitively disabled all their lives.)

If there is not a clear understanding of the patient’s wishes in the particular situation, the decision falls to the designated power of attorney for health care or whoever is in the decision-making role. Few of us would choose to be severely disabled and we would not want that for our loved ones. Yet, as Christians, we do not consider the lives of the severely disabled meaningless. They are made in the image of a God who loves them and is working for the good. The love that we show them may demonstrate the love of God to a watching world.

The difficult situation lies with the patient who is mentally incompetent, has not left clear instructions, and is dependent on the feeding tube to live. The tension for the Christian is to choose whether to emphasize the value of life and the fact that death is an enemy to be avoided, versus affirming the Gospel and seeing death as a defeated enemy by Christ’s own death and resurrection.

Well, that's an unbiased way of putting it. We can either emphasize the value of life or we can affirm the Gospel. Hmm. Wonder which one he wants us to pick? Once again we get the leap to theology, and interestingly, here too it comes at just the point where it seems like we are thinking the unthinkable: Here is your disabled daughter who has never expressed, perhaps never even had an opportunity to express, her wishes on tube feeding. She is not dying. (Remember? We got here by going through the "not dying" part of Dunlop's discussion. That's part of the scenario, or at least one scenario, in view here.) Refusing her nutrition and hydration will cause her death.

But instead of saying, "Well, that would obviously be wrong," Dunlop starts talking about the "death is a defeated enemy" theme again, as did Rae. It solves nothing. Nothing at all. If you are, by Dunlop's own admission, causing a helpless person's death by refusing food and fluids, you can say "death is a defeated enemy" until you are blue in the face, and it will have no ethical implications that permit you to do that thing. (I really cannot help wondering in what article or seminary this phrase was first dreamt up and applied to these situations as though it had some sort of magical power to make the contemplated action morally acceptable. Or maybe I don't want to know.)

Next Dunlop moves to the ordinary/extraordinary distinction. Finally! But there's nothing there, either.

Do we consider feeding tubes ‘ordinary’ or ‘extraordinary’ care? This is the key question in the minds of many. It may boil down to the trite “What would Jesus Do?” in a very non-trite sense. If we view feeding tubes as ordinary, they fall within the purview of Matthew 25:35-40 where Jesus commends those who feed the hungry and give drink to the thirsty, even though they are “the least of these.” It is certainly expected that we give food and nutrition to the needy. The question is, “are we expected to use feeding tubes?”

Perhaps a distinction better than ‘ordinary’ versus ‘extraordinary’ is the concept of proportionate versus disproportionate care, which was introduced by Pope John Paul II in his Evangelium Vitae of 1995. This moves the decision from the blanket “yes, no” response into the realm of “maybe.” In other words, it makes the decision context-dependent. It allows for the application of the law that Christians are under: “the law of the spirit of life in Christ Jesus” (Romans 8:2). As believers, we are not free to do anything we want; rather we are freed from the forces that have kept us from doing what is right.

So after introducing the distinction and admitting that it might be important, he drops it. "Perhaps a distinction better than..." He then throws in an ecumenical reference to JPII. I cannot tell when this article was written or last updated, but if we Protestants are to start referring to Catholic documents on this subject, we might want to refer to the Catholic document that discussed this very subject and that, to the consternation of some, stated that feeding tubes are usually to be deemed ordinary care. This statement was supportive of the statement JPII himself had made in 2004 to the effect that tube feeding should generally be considered ordinary care.

As a Protestant, Dunlop is not required to agree with any of this, but if he is going to bring in JPII and Catholic statements, it would be a good idea to update the article so as not to make it sound like official Catholic statements on this question have somehow replaced the ordinary/extraordinary distinction with a proportionate/disproportionate distinction or that a "Catholic" approach somehow favors Dunlop's own position. It does not.

Dunlop's article is disappointing. Dunlop shows a lack of information and even misinformation on the subject he addresses. He rejects the common sense view, which (though he doesn't seem to know this) dovetails with the Catholic view, that provision of food and water is ordinary care. He entertains with equanimity the disturbing prospect of dehydrating to death a non-dying person, including one who has not even expressed any such wish. And to deflect horror at such a prospect, he introduces pointless theological reflections and biblical quotations and phrases. Although his discussion is far more detailed than Rae's, it does not support his conclusion.

Update: My original summary of Pope JPII's comments as well as of the CDF document was faulty. I did not have the Pope's original comments in front of me and also did not check the CDF document and my own summary carefully. The CDF document actually says, "The administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life." And JPII, in almost identical words, actually said, "I should like particularly to underline how the administration of food and water, even when provided by artificial means, always represents a natural means of preserving life, not a medical act." Instead of qualifiers like "usually," these statements use the phrase "in principle" or the word "always," which are quite different. The CDF document continues by saying that it is 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." This allows for withholding food and fluids when they cannot accomplish the hydration and nourishment of the patient, but does not say that nutrition and hydration are ever "extraordinary care." I apologize for the carelessness on my part that encouraged a misunderstanding of the statements.

Comments (71)

Thank you so much for your thoroughgoing and insightful commentary on this subject, Lydia. We are all much in need of the light you shine on these issues.

Thanks Lydia.

In light of some of the long discussions you've joined on my FB page, I was really hoping to see you post some commentary much more detailed than comment boxes allow for. It's sad that things like this even need to be discussed, but it's heartening to know that some still can. I took a few classes from Dr. Rae and things such as this did come up and I cannot say I was generally pleased with the results—though I did really enjoy him personally.

While we didn't spend as much time discussing end-of-life issues, we did spend a lot of time on the front end, and with respects paid to all as bearing the image of God, I was very disheartened to see how welcoming evangelicals were to almost any and all means of assisted fertilization (to phrase it poorly). To memory, I was the only one resistant to all of the discussed methods of 'treatment' and one of the very few resistant to /any/ means.

I'm not yet able to posit a full defense, but I cannot accept that our 'flexibility' with ethics at both beginning and end of life discussions are not directly related.

Thanks, Rob. I assume when you mention assisted fertilization you are referring to IVF or even donor sperm artificial insemination? I think you are probably right that there is a connection between accepting that and taking certain positions regarding end-of-life issues, though so far it seems to me not to be an absolute logical connection though having logical components.

Aside from anything else, there are major sociological forces at work here pressuring ethicists not to be "categorical." It seems to me that one cause that may be acting on Rae, influencing him to take the position he does in the article I discuss, is that it seems to him moderate. He is being pulled on so hard from the "left," if I can use that terminology, by extremists like the people he cites who call themselves Christian ethicists but want to deny the imago dei to Terri Schiavo, etc., that he is taking a stand just to reject _their_ view and finds it difficult to die on a hill for the ordinary nature of ANH. That, at any rate, is how it looks to me.

By the way, lest anyone misunderstand your reference to FB, Robert K was _not_ the person on the "other side of the issue" who recommended these articles. I wouldn't want anyone to attribute that to him.

I can't help but think that behind the unnatural assistance proposed for both beginning and ending life, aside from the sheer selfishness, is a misunderstanding of what constitutes love of neighbor.

The Chicken

My 90-year-old father suffers from advanced age and dementia. I find it insulting and horrifying that anyone dare to use theology to suggest that it would be a good thing for him to starve to death. Thank you, Lydia, for continuing to shine light on this issue and keep us aware of the many ways life is NOT being affirmed, even by those in the church who claim to be pro-life.

Y'know, I can't help feeling, Beth, that even Christian bioethicists (like these) have this tremendous motivation to designate as "legitimate for dehydration" a group of people who satisfy the following criteria:

1) Has some sort of identifiable health condition of which he is expected to die eventually.

2) Needs tube feeding, for whatever reason.

But

3) Will not die of the identifiable condition within an extremely short time period, such as a few days. Will die of the dehydration long before he would die of the so-called "underlying" condition.

Now, once you single out this group of people and say that it is okay to leave them without the tube feeding, the rationale for treating this group as a "natural kind" becomes extremely problematic. For example, if the person isn't dying _that soon_ of his condition, and if (were we honest) we should have to admit that the _proximate_ cause of his death would be the dehydration, what ethical difference should it make that he even _has_ the condition? After all, if we shot a cancer patient in the head, we wouldn't try to fool ourselves that he died of cancer! Why even call the condition "underlying"? It isn't "underlying" his death, if he dies of simple lack of water within the normal time period that anyone would be expected to die if, for example, stranded in the forest with a broken leg and without water. Would we say that the person in that case died of the "underlying" condition of a broken leg? Obviously not. So it must be the need for tube feeding. Yet Dunlop & co. don't want to say that it is _always_ legitimate to let a person dehydrate to death if he needs tube feeding. Dunlop appears to think that tube feeding _should_ be given if the person is expected to recover from some other condition and get to the point where he can eat on his own. But why is the expectation of recovery crucial to the question of whether food and water should be given? We don't give healthy people food and water to help them recover from anything but just to keep them alive in the ordinary sense.

In other words, there is this strange interaction between the mere fact of some other condition (even though the person is not immediately dying of that condition) and the need for tube feeding that is supposed to be greater than the sum of its parts. It's like a chemical reaction. Neither of the two things is ethically sufficient all by itself, but for reasons which these ethicists don't seem able to articulate to the satisfaction of a doubter, the _conjunction_ of those two factors makes denial of food and fluids until death legitimate.

I might just add, FWIW, that in Oregon it is required that people who have been given a lethal prescription and died from taking it have their death certificates falsified so that they are said to have died of their "underlying condition"--the condition that led to their seeking physician-assisted suicide.

Hey Lydia!,

Great work here! I am in the midst of a blog post where I defend statements that I made regarding this subject on a web interview. This is simply outstanding work and I am grateful to providentially have it to review as I further explain my own arguments.

Jay

Thanks, Jay! The linked articles by Smith are full of a lot of good information.

Be sure to tell us where your blog post appears, Jay.

Thanks, Rob. I assume when you mention assisted fertilization you are referring to IVF or even donor sperm artificial insemination? I think you are probably right that there is a connection between accepting that and taking certain positions regarding end-of-life issues, though so far it seems to me not to be an absolute logical connection though having logical components.

Yes, that is what I meant. And again on the second part about connection I would also agree. I didn't mean to imply (and it doesn't seem it was taken in such away) to mean that one necessarily follows the other, only that each seems to be an outworking of a similar philosophy. While it's certainly not applicable to everyone on either early or end of life issues, it seems to me reasonable to think that as people are valued less and less for who they are and more as what they do or what need they fill, that crossing boundaries to 'aid' in the creation process (and also remove early the unproductive, e.g. unborn with down's syndrome) would only naturally be accompanied by a desire to 'compassionately' remove those that create a burden at the opposite end of life. Whatever it's called, that's not care.

I think you are quite right.

I also think, though this is going in quite a different direction from your comment, that both sets of attitudes (beginning of life and end of life) are assisted on the Protestant side (and I am a happy Protestant, I should add) by a rejection of natural law in ethics and by a strange misuse of sola scriptura. If something isn't explicitly condemned in Scripture, it is implied that it's well-nigh impossible to condemn it categorically as wrong. Of course, we could all dream up all sorts of horrors that are not explicitly condemned in Scripture. I remember in this connection a conversation with a friend some twenty years ago about donor-sperm artificial insemination. She said that she did not believe it was wrong because it wasn't adultery--"adultery" being defined, of course, as involving the physical act of sexual intercourse. There was very much a sort of narrow notion of ethics at work there--that if something doesn't fall strictly into a list of pre-named sins it cannot be seriously wrong. I suppose that some of the end-of-life issues are analyzed in the same way.

This would fit with Dunlop's odd use of Scripture. There is something at the same time vague and opportunistic about it. When a verse seems pretty obviously applicable, such as the commendation of those who give drink to the thirsty (!), he brushes it off by saying that it isn't about feeding tubes. When it can be applied in some purely rhetorical way, such as the verse about "the law of the spirit of life," then he brings it in.

Lydia, good post. It is important to keep in mind that water and food are not medical care or interventions, but merely ordinary care for a person. And that even a dying person should not die of dehydration if we can prevent it. It is one thing to allow their actual disease to kill them. It is another thing again to kill them through withholding food and water.

(Anecdotally: my mom died at home of cancer 3 months ago. We were able to feed her significant amounts right up until the day before she went into a coma, which was 2 days before death. I cannot say how normal or abnormal this was.)

That said, it might be necessary to make some more thorough distinctions before one can really see why a feeding tube does not usually constitute extraordinary medical care. First, the analogy with air does not really work all that well.

the fact that we do not usually have to give people, even helpless and sick people, air at all

When we humans get to living on space stations and space ships, the supply of air will neither automatic nor free. Every breath we take will be at some cost or other, and sometimes only by a positive action from someone else. One can easily imagine a future pioneer John Smith saying "if they will not work, let them neither breathe nor eat." Which obviously should not apply to children nor the aged. I am just pointing out logical areas of concern. The fact that we usually don't have to make a positive step to cause someone to have air available does not illustrate a basic principle.

With a feeding tube, I can imagine someone arguing this: well, if a feeding tube is not medical intervention, then where does it stop? This guy not only cannot chew and swallow, he also cannot digest. So we have to supply him with pre-digested food. That guy's intestines cannot absorb the food, so we have to put it directly into his veins (TPN). While I am not absolutely comfortable with a claim that a feeding tube is medical intervention, I sure as heck am much more uncomfortable trying to hold that intravenous TPN is not medical intervention. There is a decent case that if a person who is normal in every other way has a failure of his mouth and throat muscles, so that he cannot swallow, a feeding tube gets him over that hurdle. But almost by definition, "getting over the hurdle" of a malfunctioning bodily component to accomplish an integral life activity is a medical activity. The specific method (either nasogastric tube or percutaneous endoscopic gastrostomy (PEG) tube) is an artificial manner of bypassing the normal action of chewing and swallowing. Since the acts of chewing and swallowing begin the integral process by which the person makes something out there into his own flesh (I say integral because eating the food not only places the food inside the body, it also grinds it and adds saliva, which initiate the process of digestion), this suggests at least on the surface that bypassing chewing and swallowing is conceptually different from spoon feeding a person. I.e. that the tube it is medical care rather than nursing care.

Given that, where is the burden of proof for a claim here: that it is, or that it is not, "medical treatment"?

It is a completely DIFFERENT question as to whether the action is ordinary means or extraordinary means of sustaining life and health. As you so rightly maintain, providing food and water by spoon feeding etc. is ordinary care. Pope JPII proposes that providing food and water by tube is usually ordinary care also. I think this makes a great deal of sense: even for a dying person, you don't actively want them to die, so of course you don't want them to die of dehydration, and you do what you can to prevent this. This is such a no-brainer. Usually, even for a person with cancer, tube feeding is just a means of giving their body what it needs to be a living being.

The argumentative problem here is that the most JPII can say is that it is usually ordinary care, not extraordinary. Which means that sometimes using a tube is extraordinary care. What would be the necessary distinction to help us understand when (and why) is it sometimes ordinary and other times extraordinary? That seems a bit harder. What seems especially difficult here is that most discussions from this point forward do not bring forth any principle, but rather descend into questions of "what would the patient want", and cost/benefit ratios.

On the one hand, I would be willing to go along with a general notion that when the theory hits the flesh, there are gray areas that cannot be definitively resolved as certainly yes or no for or against the tube being extraordinary care. But come on, since when does "what the patient prefers" create a basic moral reality about caregiving? Sometimes what the patient prefers is immoral, and part of our job is to give them support to help them outgrow that preference, if possible.

And as for cost/benefit ratios, I would be more inclined to listen to them if someone could explain to me the correct offsetting correlative (cost/benefit-wise) to suffering gladly what God asks you to suffer for His sake. When looked at properly (through God's eyes), will that suffering be put on the cost side, or the benefit side? When "All things work to the benefit of those that love Him."

And in other consideration: cost/benefit ratios can only come into play once you have already decided that in this case the tube may be extraordinary care, depending on the particulars like this cost/benefit ratio. But that just kind of begs the question as to whether there is an earlier determination (based on that quiet principle or standard that nobody wants to bring forth) that does NOT already decide that in this case it must be ordinary care, so you cannot begin to weigh the costs against the benefits.

All this suggests that perhaps the really critical (and morally safe) determination of cost/benefit is limited to the medical sphere itself. Will the medical results from this kind of care (increased risk of infection, etc) be compensated by the benefits? At this level, it is obvious that the medical benefits from tube feeding someone outweigh the costs for nearly everyone except a person who is already within, say, a month of death from other causes. Or, from someone whose medical condition cannot benefit from food and water being in the stomach. Yes, that kind of strictly medical cost/benefit weighing I can see.

But I worry if this does not actually too strong a limit on the notion of extraordinary means of sustaining life. I used to think that extraordinary means implied methods of sustaining life that would in fact be medically beneficial, but the patient would not be obliged to seek or accept. What the above consideration seems to resolve to is that we are obliged to use measures that medically can do the patient some good, and after that point not only are we not obliged to, there is no particular reason to want to. But that cannot be what "extraordinary" care means.

Is this an idea of which we say "I can't define it, but I know it when I see it"?

Lydia, I think you are completely right when you state:

"It seems to me that one cause that may be acting on Rae, influencing him to take the position he does in the article I discuss, is that it seems to him moderate. He is being pulled on so hard from the "left," if I can use that terminology, by extremists like the people he cites who call themselves Christian ethicists but want to deny the imago dei to Terri Schiavo, etc., that he is taking a stand just to reject _their_ view and finds it difficult to die on a hill for the ordinary nature of ANH."

both sets of attitudes (beginning of life and end of life) are assisted on the Protestant side (and I am a happy Protestant, I should add) by a rejection of natural law in ethics and by a strange misuse of sola scriptura. If something isn't explicitly condemned in Scripture, it is implied that it's well-nigh impossible to condemn it categorically as wrong.

That reminds me of the paper Moreland drew criticism for maybe a year or two ago called, "How Evangelicals became overdependant on the Bible, and what can be done about it," or something like that. This was I think his big point, that we can know things outside of Scripture. From memory, he went to great pains to explain that there are some things that we cannot know from outside, and that the authority is still final, but uses a really obvious example like a Christian archaeologist that discovers a new civilization on a dig need not consult Scripture to see if it's real. Sadly the point was lost on many that could have benefitted as the unfounded attacks came in.

I hope that made sense, it's not yet 5 am and it was a long night with our baby. She thought it was time to laugh and sing for 2 hours last night. Not at all unpleasant to hear, but not preferable on the timing. =)

Really great comments, folks, and I mean to respond to them later today. I have to go out for a while this morning. Rob K, I won't tell you, "Ah, enjoy her while she's this little," etc., while you're feeling like a zombie and maybe even miserable from being up all night, but I will just say that when she is twelve, believe it or not, you _will_ look back on these singing-laughing at 2 a.m. nights and kind of smile to yourselves.

who argue that a person in a PVS has lost the image of God or that the "person" is dead even if the body is alive

*Sigh* This is why philosophers and theologians tend to do more harm than good. It's axiomatic that if the brain is still functioning on a level that would keep the bodily systems functional, that the person is alive. Terri Schiavo was alive simply because her brain was capable of regulating her organs to keep her alive. Her inability to feed herself, as you said Lydia, is no more relevant than an infant's inability to feed itself, to the fact that her body was still quite functional.

Life is not a medical condition. It is an ontological or existential state. At what point does it become proper to do a cost benefit test on an ontology? One problem (and it is a big problem) is that few people in the medical profession actually understand the relationship of the soul to the body. In fact, it seems as if some people, including ethicists think that the soul is merely something trapped in the body to be set free. Ask them about why we will have bodies, again, at the Second Coming and forever, thereafter, and they will have no clue. St. Paul went to great lengths to discuss the relationship between the soul and the body, in part, to get people to understand that the body is ann essential component of what it means to be human. Killing the body is never a benefit. Starving the body to death while it is crumbling is treating the temple of the body more like a parking garage than a temple and ethicists like a hal-mad city council intent on changing the zoning laws. We reverence and admire even crumbling old temples in the world. We even pay to preserve them in their crumbling state simply for the history they contain. Talk about hypocrisy.

Of course, there will be dangers of coming to a consistent view of how to deal with end of life issues when other cultures and religions are thrown into the mix, but it is maddening to see that even Christian ethicists can't be consistent.

The Chicken

I won't tell you, "Ah, enjoy her while she's this little," etc., while you're feeling like a zombie and maybe even miserable from being up all night, but I will just say that when she is twelve, believe it or not, you _will_ look back on these singing-laughing at 2 a.m. nights and kind of smile to yourselves.

Oh, I'm smiling now. And the midnight giggles are much better than the midnight crying =) I mean, I miss getting as much sleep as before (and I KNOW my wife sure does), but these last 5 months of sleep shortage have been the best 5 months ever. =)

Rosemary Munkenbeck says her father Eric Troake, who entered hospital after suffering a stroke, had fluid and drugs withdrawn and she claims doctors wanted to put him on morphine until he passed away under a scheme for dying patients called the Liverpool Care Pathway (LCP).

Mrs Munkenbeck, 56, from Bracknell, said her father, who previously said he wanted to live until he was 100, has now said he wants to die after being deprived of fluids for five days.


http://www.telegraph.co.uk/health/healthnews/6156076/Daughter-claims-father-wrongly-placed-on-controversial-NHS-end-of-life-scheme.html

Doctors left a premature baby to die because he was born two days too early, his devastated mother claimed yesterday.

Medics allegedly told her that they would have tried to save the baby if he had been born two days later, at 22 weeks.
In fact, the medical guidelines for Health Service hospitals state that babies should not be given intensive care if they are born at less than 23 weeks.
The guidance, drawn up by the Nuffield Council, is not compulsory but advises doctors that medical intervention for very premature children is not in the best interests of the baby, and is not 'standard practice'.
James Paget Hospital in Norfolk refused to comment on the case but said it was not responsible for setting the guidelines relating to premature births.


http://www.dailymail.co.uk/news/article-1211950/Premature-baby-left-die-doctors-mother-gives-birth-just-days-22-week-care-limit.html#ixzz0QYlC8aeX


Read more: http://www.dailymail.co.uk/news/article-1211950/Premature-baby-left-die-doctors-mother-gives-birth-just-days-22-week-care-limit.html#ixzz0Qcm2vJS0

Life is not a medical condition.

I know what you mean, but it is a biological state of the body. For the average person, it would help to understand life as a pyramid with the biological state as the foundation for life in the material world, with all spiritual, theological and philosophical considerations building on that. If they understand it is as a pyramid with the biological state as the foundation, then they understand that higher considerations cannot trump the foundational value which is rooted in biology and common sense and observation.

Kevin, I notice some of the same stuff being uttered in that article about that poor man who is a stroke victim that we read in these articles. For example, something like, "Providing treatment can cause unnecessary suffering." This poor man has been without fluids for _five days_ simply because he has had a stroke. He's actually communicating with his daughters. He's miserable. What is causing his suffering? Obviously, it's the withdrawal of fluids. Simply horrible. Yet the medical people are still mouthing what they have been taught to say, like automata.

Hitherto I have regarded England as somewhat better than America in terms of dehydrating people to death. Legally, they have no Cruzan precedent nor its many legal spin-offs at the state level. But that has obviously changed.

RobK, I think what you say about Moreland is right on-point. In fact, someone brought up Moreland's speech to me once before when I was making similar comments. It seems to me that an unduly narrow view of the implications of Christianity can leave Christian academics very vulnerable to all sorts of compromises that look exceedingly weird to everyone but the person himself. This is true in metaphysics, too. I don't remember the name of this female Christian philosopher, though I think I'd recognize it if I heard it. Anyway. some years ago I heard that she said at a conference, "I can now dispense with all finite spirits." I mean, what are we supposed to say? "Congratulations! You are now _almost_ ready to get your metaphysical naturalist's card, if they'll just make an exception for God."

Tony raises some extremely interesting questions and points that I want to respond to, and I appreciate them. I would stand by what I said about "giving air." I don't think the outer space point really addresses it, because a person whose basic bodily functions are working will still _draw in_ the air on his own, automatically. So he doesn't have to be "given" air in anything like the sense in which a baby has to be "given" food. This is related to the fact that breathing is a basic bodily function but that _eating_ is not. That is to say, we are still functioning even when we are asleep and are not only not eating but are not able to eat, because we're too "out of it." And that is of course one of the things that gives rise to the need for a feeding tube: The person is "out of it"--unconscious or, especially in very elderly people, extremely sleepy. So supplying a ventilator is replacing a basic bodily function, whereas giving a feeding tube is not.

This doesn't mean a ventilator couldn't be sometimes obligatory. Brain surgery, though obviously a treatment, invasive, and extraordinary, could sometimes be obligatory, so clearly a ventilator could be as well. It's just that it seems to me that this distinction between replacing what everybody's body does, every moment of the day, automatically, with technological assistance, is clearly "extraordinary" in a sense that cannot even remotely be applied to a feeding tube, which is not replacing that sort of constant, basic function of the organs.

You bring up the fact that bypassing the mouth does mean bypassing the early stages of the digestive system. I agree, but like you, I don't think this makes the use of the feeding tube extraordinary care.

It's maybe worth noting that in a great many cases, though not in all, people on feeding tubes are able to swallow small amounts, but there is a concern about safety, and especially about safety for the amount of intake necessary to sustain life. Terri Schiavo's throat muscles were significantly atrophied (because they had stopped even small amounts of mouth feeding years before at her husband's insistence), but she could still swallow her own saliva. So for what it's worth, it would be a mistake to think that in all or even most cases of feeding tube use we are considering a person whose entire ability to receive and swallow by mouth is completely paralyzed and that that is the reason for the feeding tube. On the other hand, I would consider tube feeding ordinary care even in the case of such a paralysis.

You (Tony) raise the question of when tube feeding could be extraordinary care. We might want to consider that when the Pope, etc., said that it is "usually" to be regarded as ordinary care, it doesn't necessarily follow that they were saying that in other cases it is "extraordinary care." A useless attempt to supply something that cannot be taken in--as when food and fluids literally cannot be assimilated and used--would be another alternative to ordinary care.

But I suppose if we felt it necessary, we could imagine a case where a feeding tube _might_ be extraordinary care: Suppose that a patient is strongly expected to die of some other illness within 48 hours and that he has fallen into a semi-conscious state and is not swallowing anything more than tiny quantities of fluids. A feeding tube might then be considered "extraordinary," because he is expected to die far sooner of the illness than he ever would of dehydration, and also because he can be given small amounts of fluids for comfort in the meanwhile.

My own inclination would still be to ask for an NG tube for many reasons, one of which is that I consider predictions that someone will die within 48 hours to be dubious. In the UK, attempts to make such predictions have had terrible results, such as the man in the story Kevin linked above, a conscious and communicating stroke victim who has now been without fluids for five days and is suffering from dehydration. But _if_ one really had a crystal ball that showed such a very, very imminent death, then it might make sense to regard a feeding tube as "extraordinary care."

Yeah, Lydia, you have to be impressed by Hell's cruel logic; "your father wants to die now that we are killing him. Why are you denying him his wish?" How could so many of those in the healing arts become so corrupted?

Hitherto I have regarded England as somewhat better than America in terms of dehydrating people to death

Forget the canary in the coal mine, all these horrors pouring out of the U.K. make it the corpse we have to step over on the way to Obama’s rationing regime.

You bring up the fact that bypassing the mouth does mean bypassing the early stages of the digestive system. I agree, but like you, I don't think this makes the use of the feeding tube extraordinary care.

The Pope would agree. His exact words from the 2004 speech are:

"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, 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." (Italics his.)

I don't see the word "usually" but "in principle." And since such care is not even to be considered "a medical act" but a natural means of preserving life, the fact that it is delivered artificially is not merely trivial, but irrelevant.

I appreciate that, Bill, because it looks like some of the secondary representations of what JPII said have not been quite accurate.

Luse is right. Tonight, I will be eating with a fork, an artifact by which I administer food to myself. But that doesn't make the eating artificial.

Lydia, I was agreeing with your point that generally the tube is not extraordinary care, but ordinary. What I was claiming is that, while remaining ordinary, a reasonable argument can be made that it is medical care in nature. You didn't really address that.

Bill, however, did. Thanks Bill for that quote from JPII, that greatly tightens up what we are attributing to him. (Can you say which speech it came from?) I fail to see that he is presenting any kind of an argument here, though, just a claim. A rather bald claim at that. Not that I necessarily think he is wrong here - I would wait until I see his line of reasoning.

Until I understand his underlying thinking, I would suggest that there are pretty reasonable arguments to the other point of view. I already gave one: where does artificial cease to be non-medical care and become medical care - when we get to intravenous TPN? Or how's this: " Circulation of the blood is natural. Even if we keep it going through artificial means, that is not medical care, it is just a natural means of preserving life. SO use of a blood pumping machine is not really medical care.

The Pope begs the question, or covers up the problem, with his use of the word "administration" in referring to "administration of water and food." The natural expression is to feed someone. For those who are whole and hale, to feed them is to offer them food and let them eat it. To those who are weak or ill, feeding them often implies spoon-feeding. But in either case, the natural concept for "feeding" the person does not include physically forcing the food directly into the stomach by external means.

It is not natural to "administer" food to the stomach absent the predecessor tasks of chewing and swallowing, because those predecessor tasks change the food for the body, prepare the food for the stomach's action. The fact that the stomach can manage without is, I think, an irrelevancy. (Your body can manage without a spleen, that doesn't mean doing without it is natural. You can manage short a kidney or a lung - is bypassing them natural?)

With a stomach PEG tube, the whole process requires an unnatural opening into the body. You can't really call this just "natural" supplementation of bodily activity.

The Pope goes on to say

Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality,

If I get the drift, he is stating the same thing I suggested tentatively: that the proportion is a strict one in terms of medical good, and implies using the tube until the person cannot really benefit organically from food anyway, because the whole nutrition system is shutting down. But he seems to further indicate that this proportion stems from its characterization as "ordinary" as opposed to medical. I wonder whether it needs that base, whether you can maintain the conclusion regardless of whether the tube is correctly considered ordinary or medical.

I am thinking of this situation (among others): if out in the hinterlands of Africa, a person could obtain the needed supplies for tube feeding, but only at a quite considerable cost (say 3 months family income), does the fact that this is merely "ordinary" care in principle mean that they are obligated to spend the money and obtain the equipment, cost-be-damned? I really think that throwing in the phrase "in principle, ordinary and proportionate" really makes it difficult to understand.

I need to update the post to correct my summary of the Pope's comments, which I got from a secondary site. Those comments are incorporated word-for-word, as far as I can tell, into the CDF document I link as well.

Tony, I think that when the Pope contrasts "natural means" and "medical act" he is expressly going up against the type of legal fiction current in American law, dating of course to Cruzan, according to which ANH, because done through a tube, is regarded as treatment and hence is classified with, say, medical drugs. As such, it is considered as licit and as much a right for a person to refuse it either for himself or for a patient whose best interests he is supposed to represent as for him to refuse, say, spine surgery or chemotherapy. Now that is obviously wrong, and this legal idea that ANH is "treatment" has caused all manner of mischief. For one thing, regarding it as treatment implies, just as Dunlop does above, that it has to be justified in some terms other than providing nutrition and hydration--that it has to be justified by saying that it will help the person recover from some other problem, get better than he was overall when you started giving the ANH. The Pope and the CDF are challenging this, and rightly so. They are saying that the telos of ANH is just nourishing and hydrating, whereas regarding it as a "medical act" (aka "treatment") implies that it has some other telos and cannot be justified except to the extent that it fulfills that other telos.

The Pope wasn't denying, because there would be no point in denying, that a certain amount of special skill, knowledge, and equipment is involved, though I am bound to say that even non-medical people can and do learn to maintain a feeding tube and administer tube feedings once a tube is in place and even that, though probably illegal (and understandably so), it would be in principle possible for a person without a medical degree to learn the skill required to insert an NG tube.

To me, your scenario with the family is somewhat analogous to something very strange like this: Suppose that some adult children are for some elaborate reason physically unable either to come to an aged mother or to have her come to them. She is eating by mouth just fine but has become quite weak and bed-ridden. They will have to pay an exorbitant sum such as you cite just to get someone to come and give her basic nursing care, even changing her diapers, and preparing her food. This is the only way for her to get this care. The alternative is for her to die soon, completely untended, of starvation and neglect. Are they obligated to scrape up that money to the extent that they are at all able to do so? Well, of course. See, the scenarios involving crazy cost, nobody to help, and so forth, can just as easily be applied to any nursing care at all as to tube feeding. If anything, day in and day out basic nursing, especially over years, is _more_ expensive in the real world, as opposed to in the world of hypotheticals, than the mere equipment or even the minor surgery for PEG tube insertion. So the fact that one can make up such a scenario tells us nothing ethically useful, in my opinion.

I am thinking of this situation (among others): if out in the hinterlands of Africa, a person could obtain the needed supplies for tube feeding, but only at a quite considerable cost (say 3 months family income), does the fact that this is merely "ordinary" care in principle mean that they are obligated to spend the money and obtain the equipment, cost-be-damned?

This is a seriously flawed understanding of how the word "ordinary" is actually being employed within the text of the subject CDF document.

Obviously, food and water are basic necessities of life, and if and when these cannot be self-administered, it's incumbent upon other people to do it for the sake of that person.

However, when and where either food and/or water itself, or the means by which these are administered in and of itself, becomes excessively burdensome, then it may be licit (Protestants understandably might not be familiar with this term of art which carries with it a specific meaning in Catholicism; hopefully, certain Catholics might -- although I wouldn't be surprised if certain Protestants were more familiar with the term as rightly understood within Catholicism than most modern-day Catholics who are supposed to) to refrain from imposing the specific burden of such means upon that very person.

It must be understood though that this is essentially different from deliberately withholding food and water because of some arbitrary judgment concerning a person's current quality of life in general which doesn't warrant extending their life (i.e., because of such a sorry existence merely extended by an apparatus, that person's life should suffer swift expiration).

That is to say, no matter how terrible that person's condition, if there were a way to provide nutrition and hydration in such a way that is not itself unduly burdensome, it would be incumbent on us to do so.

We do not withhold food and water simply because we personally believe that they should not suffer such a sorry life as that. Yet, keep in mind that we only do so when there is no way of administering it that is not itself unduly burdensome.

Thus, the CDF document clearly indicates that withholding nutrition and hydration is only done in rare instances where it is found to be exceedingly burdensome for the patient, such as significant complications that may in fact arise due to the very utilization of such means by which sustenance is provided.

Can you say which speech it came from?

This one.

I have serious doubts as to whether financial cost in itself can render ordinary care "unduly burdensome" in any sense that would be recognized by the Catholic understanding of natural law. That certainly does not seem correct given _my_ understanding of natural law. See my example above of the elderly lady who has to die unwashed, unfed, etc., in her bed unless her children come up with a lot of money.

Tony, I think that when the Pope contrasts "natural means" and "medical act" he is expressly going up against the type of legal fiction current in American law, dating of course to Cruzan, according to which ANH, because done through a tube, is regarded as treatment and hence is classified with, say, medical drugs.

I thought he was speaking with a more general standard of usage in mind (not just a U.S. position on "medical treatment"), since, after all, the CDF's explanation is based on Pius XII's comments:

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.

Ari objects to my African example as a depiction of the consideration of ordinary:

This is a seriously flawed understanding of how the word "ordinary" is actually being employed within the text of the subject CDF document.

I admit that this example was thrown out with somewhat less than full thought, so it may be flawed. But it focuses in exactly on issues that DCF itself raised:

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

If you change the venue, so that the tube DOES "impose a heavy burden", or DOES involve "excessive expense", or is NOT within the capacity of the health care system that you have at hand, then NO, you cannot assume that it is ordinary care, at least by CDF's own standards.

To be more explicit, it might appear that the CDF is denying that the issue of whether an act is "medical treatment" or is merely ordinary human care is NOT part of the determination of whether it is obligatory, or whether it is "extraordinary" means that may be rejected.

"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.).

Thus there seems to be two separate versions of "ordinary" running around: ordinary versus "treatment" or "medical", and ordinary means as opposed to extraordinary means. CDF seems to be pretty explicit here: there are medical treatments that must be considered ordinary rather than extraordinary. That's why I started off my first post suggesting that we keep separate the discussion of "medical treatment" from the discussion of whether it is extraordinary.

In that context, the Pope's comments that artificial means of providing food and water are a "natural" means of sustaining life actually muddy the waters, rather than clarifying the issue.

I am NOT arguing that use of the tube is extraordinary, or that it is not usually obligatory. I am concerned with the manner by which we come to the conclusion that it IS normally obligatory. The only fully and readily coherent concept and term provided by the CDF throughout the document seems to rest on "minimal", not "non-medical", - things that are minimally burdensome, are minimally necessary for sustaining life, and involve actions which are minimally co-optive of difficult medical methods can be and generally are obligatory. This standard is understandable in the general sense, but is frustratingly difficult to apply in the particular case: it simply demands application of prudential judgment on issues which hinge essentially on matters of degree, of more and less, so that reasonable people can differ on the decision in a given case.

I have serious doubts as to whether financial cost in itself can render ordinary care "unduly burdensome" in any sense that would be recognized by the Catholic understanding of natural law.


As I said previously:

[F]ood and water are basic necessities of life, and if and when these cannot be self-administered, it's incumbent upon other people to do it for the sake of that person.


Besides, as the document itself declares:

...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...


Suppose that some adult children are for some elaborate reason physically unable either to come to an aged mother or to have her come to them. She is eating by mouth just fine but has become quite weak and bed-ridden. They will have to pay an exorbitant sum such as you cite just to get someone to come and give her basic nursing care, even changing her diapers, and preparing her food. This is the only way for her to get this care. The alternative is for her to die soon, completely untended, of starvation and neglect.


As Catholic Morality teaches:

Death can never be either the end of any licit act, nor the means to any legitimate end. Death can only ever be the foreseen, accepted but unwilled consequence
of some licit act which is itself ordered toward some other good.

Therefore, in addition to all those things previously mentioned, it would indeed be morally illicit to cause the death of that aged mother.

However, what you and Tony are dwelling on are not actually matters that the CDF document itself was in fact addressing. It concerned the patients themselves in PVS and with respect to the artificial means employed.

More to the point, there may be instances where it could be deemed licit not to provide such artificial means to the patient where under rare circumstances, certain complications as a result thereof would prove all too exceedingly burdensome for that patient.

This would prove a more interesting discussion if only we stick to what the CDF document itself was actually addressing rather than some hypothetical scenario taking place in Africa or some impoverished family.

For example, how about providing examples of those rare instances or whether there are indeed instances in the first place; and, if so, why?

The examples the CDF commentary gives (not linked above--the commentary is a separate document, which Tony is quoting) are A) where the food and fluids literally cannot be assimilated or B) where the patient himself is harmed in some other serious way by complications arising from the administration itself.

I would say that A makes sense if it is really, literally true, though I'm not sure how many doctors I would trust if they told me it was going on. I know of one case (I believe the woman's name was Maria Korp) where she died over the usual 10 days even though the person who made the decision (IIRC it was her guardian ad litem) claimed that she was not "profiting from" the food and fluids--words to that effect. Some took this to mean she could not assimilate them, but when what he said was examined more closely, it was only that her condition was not generally remaining stable while she was being fed, which is not the same thing. And the time that it took her to die indicated in my opinion that she did indeed die of dehydration and was previously being nourished by the food and fluids. So I think even A can be thrown around promiscuously.

As for B, the CDF commentary only uses some phrase like "the possibility is not absolutely excluded," which seems to imply even on their part a doubt as to whether it ever arises. My own inclination would be to treat any such problem (for example, discomfort from infection at the site) and to say that it never arises that somehow one would be unable to treat the problem or get around it and would therefore "have to" withdraw the food and fluids, when they were nourishing the patient, because of this other "burden" to the patient. This one is far easier to abuse even than A. "Oh, the patient has an infection at the PEG site. Gotta stop food and fluids. Too bad he'll have a lot worse than an infection in two weeks; he'll be dead of dehydration." Not that I think the CDF is encouraging this kind of frivolous application.

I would note that even though the commentary mentions the fact that ANH does not involve excessive expense, "excessive expense" is not one of the examples they give later as rare exceptions. And a good thing, too.

A moral doctrine is not rendered confusedly "muddy" or somehow flawed if it fails to unequiviocally address every hypothetical, far-flung example raised to test it. The search for a perfect, universally applicable rule that can encompass all conceivable exceptions may make for a riveting intellectual exercise, but the fact that it requires such strained efforts only confirms the soundness of the teaching.

The Christian life is lived with a great many tensions and challenges. The hardest may be adopting the consciousness of Christ at the cost of those rational principles, theories and systems we hold so dear.

The examples the CDF commentary gives (not linked above--the commentary is a separate document, which Tony is quoting)...

Yes it is linked above. The commentary follows the CDF answers to the two questions in this URL:
http://www.ncbcenter.org/CDF-FoodwaterPVS9-14-07.pdf

...since, after all, the CDF's explanation is based on Pius XII's comments

It's actually based on a misinterpretation of Pius' comments. 1st sentence 2nd paragraph.

Tony seems to be in agony about something: ...is frustratingly difficult to apply in the particular case: it simply demands application of prudential judgment on issues which hinge essentially on matters of degree, of more and less, so that reasonable people can differ on the decision in a given case.

What case would that be?

It's easy to show what's wrong with these articles, as other commenters have. My question is, why are these published by a putatively Christian organization with strong pro-life/anti-euthanasia folks on the board of advisers? Are those people who allow their names to be indirectly attached to this anti-Christian blather asleep at the switch?

I think it's useful to remember that crazy hypotheticals can be made up about _any care_. What if there were a newborn baby who could not be touched without causing him extreme pain? Stuff like that. And I already demonstrated this w.r.t. cost. We can imagine a situation in which any care whatsoever for a helpless person costs huge amounts of money. What this shows is that these hypotheticals are useless for making distinctions between medical and non-medical, natural and unnatural, etc. Obviously, in such a nightmarish situation we would try to find our best way around the extreme block to normal care, but that wouldn't make the care any less normal; it wouldn't make it a "medical act" to pick up the infant and feed him, for example. I think this point is obscured by the fact that when people worry about ANH they are more likely to envisage weird hypotheticals in connection with ANH and don't realize that you can do that with anything. Years ago a correspondent made a similar move: "What if giving ANH would impoverish a family?" At the time I wasn't on the ball and didn't think of pointing out that you can say that about anything at all: "What if all food were exorbitantly expensive, so that for parents to feed their children at all would impoverish them?" See. It tells us nothing about what kinds of acts we are contemplating.

Mr. Rosenberg, I think that the articles speak for themselves. Scott Rae is a pretty well-known Christian ethicist, and I hear he's a very nice guy. I think what these articles show is an attempt to develop some kind of "evangelical ethics" that on the one hand rejects the horrors of secular personhood theory (denying personhood to the severely disabled) but on the other hand is what they view as "moderate" (in some good sense) on the issue of ANH.

Kevin says:

A moral doctrine is not rendered confusedly "muddy" or somehow flawed if it fails to unequiviocally address every hypothetical, far-flung example raised to test it. The search for a perfect, universally applicable rule that can encompass all conceivable exceptions may make for a riveting intellectual exercise, but the fact that it requires such strained efforts only confirms the soundness of the teaching.

Right.

The Church can only provide a general guiding principle based on Scripture & Tradition; it leaves their actual application to specific circumstances up to the individual Christian.

For those who are simply looking for some sort of specific protocol to follow that would leave the personal exercise of thought out of the equation, you'll be sadly disappointed.

One's efforts will especially be confounded should their underlying premise be wholly contrary to the Catholic Church's ethic of life.

As stated before, Catholic Morality teaches:

Death can never be either the end of any licit act, nor the means to any legitimate end. Death can only ever be the foreseen, accepted but unwilled consequence of some licit act which is itself ordered toward some other good.


The CDF document sought to investigate the question of what means of seeking to sustain life or forestall death are actually obligatory and which are not.

The Church generally requires us to provide nutrition and hydration, which are basic necessities that all are entitled to and, therefore, when situations arise wherein these cannot be self-administered, people are morally obligated to provide this basic care to such persons.

However, in rare circumstances when, for example, the body can no longer assimilate nutrition and merely forcing food into their body becomes excessively burdensome for the patient in that, regardless of such force-feeding, because the body is unable to digest food, all such attempts actually become harmful to the patient rather than helpful; it is then in those rare occasions that withholding such artificial means is deemed licit.

A moral doctrine is not rendered confusedly "muddy" or somehow flawed if it fails to unequiviocally address every hypothetical,

Kevin, that's true. I agree with you. However, a teaching is rendered confusedly "muddy" if it is expressed in terms that appear self-contradictory, such as this:

the provision of water and food, even by artificial means, always represents a natural means

Kevin, would you kindly explain how it is that an artificial means is a natural means? It somehow is not so readily apparent to me.

The hardest may be adopting the consciousness of Christ at the cost of those rational principles, theories and systems we hold so dear.

The hardest of all may be adopting the consciousness of Christ at the cost of one of those principles "Do not do evil that good might result." Yes indeedy, worrying about principles is a fruitless task, just put on the consciousness of Christ. Never mind that keeping true to the "consciousness of Christ" requires adherence to principles known rationally.

William says Tony seems to be in agony about something:...

Bill, you are mistaken if you mean I am personally in agony about something - quite the reverse, my own extremely limited experience has never submitted me to a situation where I needed to make any decision of the sort. Kindly deposit your amateur psycho-analyst hat at the door.

I am just trying to use my imagination and extrapolate from situations I have seen to this sort of scenario: Son A, a good and lifelong Christian, with a strong prayer life and faithful service in the face of many trials, believes that the conditions are such that a tube is no longer worthwhile, the conditions have been met for no longer using it (using the guidance from CDF and JPII), and that continued use is actually harming the patient unnecessarily. Son B, a revert to Christianity with an intense love for the Church he abandoned as a youth, and on fire for Christ, thinks that using the tube is still appropriate, and removing the tube is wrong. The apparently inherent looseness of the concepts involved - when applied in the concrete case - simply do not enable us to say with confidence A is right or B is right. How does either son decide to release Mom to the other's incorrect and apparently sinful choice? How does this situation not result in a damaging rift in the family?

However, in rare circumstances when, for example, the body can no longer assimilate nutrition and merely forcing food into their body becomes excessively burdensome for the patient in that, regardless of such force-feeding, because the body is unable to digest food, all such attempts actually become harmful to the patient rather than helpful; it is then in those rare occasions that withholding such artificial means is deemed licit.

I agree with everything Ari says here, except the repeated use of the term "rare". For, so far as I understand it, in this day of advanced medical care, many if not most of the people who die of a wasting disease eventually gets to this point. I would hesitate to call rare a situation that a large share of the persons for whom this debate actually means something personal (i.e. not the people who die from a trauma, or heart failure, etc.) will actually face.
But maybe Ari means rare in the sense that even for the person for whom it is reasonable to suspect they WILL get to this point, MOST of their illness will be far from this point, so even in their case it will still be a very small portion of their overall illness.

What sort of wasting disease do you have in mind, Tony, such that you believe that the "large share of the persons for whom this debate actually means something personal" suffer from it? I'm really curious. You can't mean a stroke. Stroke patients are able to absorb food. Yet a large share of the persons for whom this debate actually means something personal are stroke sufferers and their families. You can't mean being in a PVS or being said to be in one. Yet that's also true of a large share of the persons for whom this debate means something personal. You can't mean late-stage Alzheimer's patients, who sometimes develop aspiration problems but are still processing food just fine. I'm beginning to wonder if maybe somebody has given you some medical misinformation about the widespread nature of the body's inability to absorb food vis a vis people who need tube feeding. Perhaps you are thinking of cancer. But many cancer patients _can_ eat by mouth and hence do not _need_ tube feeding but merely become disinclined to at the very end of their lives. And by "very end," I mean "very end." I don't mean "the last three years."

Another set of questions: What is going on in your scenario that makes son A think the mother is suffering unduly from her tube? How does this dovetail with the question of the mother's ability to absorb food? Is it anticipated and acknowledged by Son A that if he withdraws the mother's tube feeding she will die in the standard dehydration fashion over a period of approximately 10 days to two weeks with growing dehydration symptoms over that period? In other words, is Son A anticipating _causing_ the mother's death by withholding the food and fluids? If so, why is Son A not trying to find some means, any means, of dealing with whatever this burden is that he senses without causing his mother's death by dehydration? And in what sort of scenario *that actually occurs in the twenty-first century real world* is he literally unable to do so?

Tony:

Son A, a good and lifelong Christian, with a strong prayer life and faithful service in the face of many trials, believes that the conditions are such that a tube is no longer worthwhile, the conditions have been met for no longer using it (using the guidance from CDF and JPII), and that continued use is actually harming the patient unnecessarily. Son B, a revert to Christianity with an intense love for the Church he abandoned as a youth, and on fire for Christ, thinks that using the tube is still appropriate, and removing the tube is wrong. The apparently inherent looseness of the concepts involved - when applied in the concrete case - simply do not enable us to say with confidence A is right or B is right.

Could it really be the case that a Protestant has a better understanding of the CDF document and what JP II actually taught concerning the matter than a Catholic such as yourself?


If Son A arbitrarily decides "that a tube is no longer worthwhile"; then in such a case, Son A is deliberately starving and dehydrating that person to death by not providing the necessary nutrition and hydration that a Pro-Life ethic requires people to provide to those unable to administer to themselves this kind of basic care.

Now, in the case where death is fast approaching, time has come where a patient is no longer capable of assimilating nutrition, where force-feeding food to their system proves to be more damaging to that person's health to the point of becoming excessively burdensome; then (and only then) it becomes licit to remove said artificial means in order to allow for a natural death.

What sort of wasting disease do you have in mind,

Oh, diseases of the small and large intestine come to mind (colon cancer, anyone?). Situations where the body malfunctions to the point where you basically end up withered to a tiny shell of your former self. It is my understanding that with at least some cancers gone systemic, it is almost a matter of chance which bodily functions it screws up the most and the soonest. And, therefore:

To speak more generally, any disease where the nutritive functions may shut down before the heart finally does. And I agree with you - the end means the last few days, not the last 3 months, much less the last 3 years. So assume I am talking about the very end of her life, the last few days, and it is just there that sons A and B disagree.

What is going on in your scenario that makes son A think the mother is suffering unduly from her tube? How does this dovetail with the question of the mother's ability to absorb food? Is it anticipated and acknowledged by Son A that if he withdraws the mother's tube feeding she will die in the standard dehydration fashion over a period of approximately 10 days to two weeks with growing dehydration symptoms over that period? In other words, is Son A anticipating _causing_ the mother's death by withholding the food and fluids? If so, why is Son A not trying to find some means, any means, of dealing with whatever this burden is

Why, just the sort of scenario that CDF is implying, that Ari spelled out more: where the stomach and the intestines are not operating. Where food in the stomach is actually causing distress, without doing any good anyway, because it is not breaking down and not being absorbed. Perhaps with acute distress. Where Mom is within a few days of death anyway, regardless of any food consideration. Gee, I DID say "using the guidance from CDF and JPII." That's what I meant. And I did say so even in their case it will still be a very small portion of their overall illness. Meaning the last few days.

Now, in the case where death is fast approaching, time has come where a patient is no longer capable of assimilating nutrition, where force-feeding food to their system proves to be more damaging to that person's health to the point of becoming excessively burdensome; then (and only then) it becomes licit to remove said artificial means in order to allow for a natural death.

Could it be that I read Ari's earlier explanation of this, and agreed, and had exactly this thought in mind? Why, yes, it really could. Just, PRECISELY, this idea. And nothing else. At all. Even remotely.

OK ?

Okay. It's just that that makes this sentence a little confusing:

I would hesitate to call rare a situation that a large share of the persons for whom this debate actually means something personal (i.e. not the people who die from a trauma, or heart failure, etc.) will actually face.

Course, a lot depends on what you mean by "a large share." I think probably, Tony, that you and I approaching the statistics here a little differently because I'm running around collecting stories, anecdotes, stories about "protocols," and so forth on this stuff all over the place. This makes me painfully aware of just what a large number, perhaps even a large proportion of the people who are affected by the feeding tube debate and by the current trends in that area in health care aren't, actually, expected to have their digestive systems shut down before the rest of them shuts down. For example, you probably saw the article about the Liverpool Protocol in England, where it said that there are more and more families getting upset about their loved ones being denied fluids when they can still assimilate them. People are killed by dehydration all the time, all over the Western world--in the Netherlands, England, the U.S.

One thing that can happen is that an elderly person starts coughing and choking to some degree when eating. The doctors then decide that it isn't safe for him to eat by mouth. But maybe he's signed something (usually not fully informed) that says he doesn't want "extraordinary means" or whatever, and this is interpreted to mean tube feeding. Or maybe he actually signed something that said he didn't want tube feeding, but he had no idea what he was getting himself into. Or his relatives or the doctors decide he should be "allowed to die." So he's drugged with morphine and atavin and left to gradually die of dehydration rather than either continuing to take the risk of mouth feeding or giving him a tube.

Now, I know you're not endorsing any of that, Tony. It's just that when you start talking about "a large share of persons to whom this debate actually means something personal," it makes me wonder if you are aware of just how many people who are definitely not dying within three days, nor anything near, are affected personally by this debate.

Kevin, would you kindly explain how it is that an artificial means is a natural means? It somehow is not so readily apparent to me.

Tony, man is a social animal born with a innate desire to commune with others. Sometimes he uses artificial means, like the phone or email to do so, which are still natural to both his nature and circumstances. Does this really pose a difficult obstacle to you? Is it your claim that you found some inscrutable concept in the CDF, or that it could have been edited by a wiser authority?

Yes indeedy, worrying about principles is a fruitless task, just put on the consciousness of Christ. Never mind that keeping true to the "consciousness of Christ" requires adherence to principles known rationally.

All the principles you endlessly use to scrutinize Catholic teaching are of a limited, secondary nature. It is almost as if Burke, Smith and who knows how many other philosophers that form your library, occupy a place of primacy over the Magisterium. We not called to open the world to an inviting Unified Theory that Explains it All. We are called to offer a compelling vision of Christ.
The hair-splitting rhetoric and extraordinary exceptions you posit against encyclicals and moral doctrine reveal an imagination frustrated by an unreasonable dependence on rationality. Where is the leap of faith in your discourse?

my own extremely limited experience has never submitted me to a situation where I needed to make any decision of the sort.

The day you make way to your own Golgotha will require much, much more than the principles that sound so reassuringly sophisticated now.

Kevin, go preach to your choir, they are calling for you. Preaching to someone who has asked a question of philosophy is distinctly less useful than a clashing cymbal. If you would practice the consciousness of Christ a little more assiduously you might come to that realization. Eventually.

The hair-splitting rhetoric and extraordinary exceptions

To make distinctions is fundamental to good philosophy, as St. Thomas showed us in his thousands of questions and objections posed. Most of his points look like hair-splitting to those who don't bother to inquire deeply. The fact that you don't wish to engage the question I pose does not mean that it is useless.

ow, I know you're not endorsing any of that, Tony. It's just that when you start talking about "a large share of persons to whom this debate actually means something personal," it makes me wonder if you are aware of just how many people who are definitely not dying within three days, nor anything near, are affected personally by this debate.

Lydia, I apologize, I probably should have used a less expansive term. I was thinking more in terms of sheer numbers, not proportions. And given the number of people who die of colon cancer alone (second largest cancer killer), that's not insignificant. Neither is it a large percentage of the total number of people whose ability to feed themselves is impaired, at any given time.

The fact that you don't wish to engage the question I pose does not mean that it is useless.
Tony, what is the purpose of your question? Explain the incredible confusion you are seeking to disperse.

Your priorities are way off. Given the extreme fiscal duress bearing down on a young cohort unformed by the Christian understanding of sacrifice and suffering, yet responsible for sustaining a larger population of aging retirees, your rummaging around for hard cases and exotic hypotheticals to support the case that feeding tubes can potentially act as artificial instruments of pain and suffering, seems bizarre. But then again, you recently branded an aspect of a recent encyclical that did not conform to your "good philosophy" as appalling. Preach, I mean, ponder on.

Caleb Stegall provides an excellent quote from Ivan Illich that is relevant to this discussion;

In societies confused by the technological prowess that enables us to transgress all traditional boundaries of coming to life and dying, the new discipline of big-ethics has emerged to mediate between pop-science and law. It has sought to create the semblance of a moral discourse that roots personhood in the “scientific ability” of bioethicists to determine who is a person and who is not through qualitative evaluation of the fetish, “a life.” What I fear is that the abstract, secular notion of “a life” will be sacralized, thereby making it possible that this spectral entity will progressively replace the notion of a “person” in which the humanism of Western individualism is anchored. “A life” is amenable to management, to improvement and to evaluation in a way which is unthinkable when we speak of “a person.” The transmogrification of a person into “a life” is a lethal operation, as dangerous as reaching out for the tree of life in the time of Adam and Eve.
http://www.frontporchrepublic.com/?p=5757

This is a bunch "how many angels can dance on the head of a pin?" stuff, as Lydia so much as says in her reply to my first comment. For us even to be discussing it as if it were respectable is a victory for the anti-life folks.

Prefer treatment to inaction, save lives, don't talk about saving money by letting people suffer without treatment. Sure there will be hard cases, but it is deadly, literally, to decide in advance that you are "going to let certain people die, arguments for mercy be damned..."

Tony,

Kindly recall that you had said the following:

Son A, a good and lifelong Christian, with a strong prayer life and faithful service in the face of many trials, believes that the conditions are such that a tube is no longer worthwhile
, the conditions have been met for no longer using it (using the guidance from CDF and JPII), and that continued use is actually harming the patient unnecessarily.

Your statement herein could easily invite the more morally reprehensible interpretation that would accommodate many of the mercy-killing scenarios wherein the "tube is no longer worthwhile" can mean the sorry state of life arbitrarily determined by people like Son A who then could happen to think that death might be more preferable to that of a human life being helped by an apparatus meant to save that person's life, and where "actually harming the patient unnecessarily" can mean the ordinary discomfort of an inserted tube.

This is why I felt compelled to point out more explicitly:

If Son A arbitrarily decides "that a tube is no longer worthwhile"; then in such a case, Son A is deliberately starving and dehydrating that person to death by not providing the necessary nutrition and hydration that a Pro-Life ethic requires people to provide to those unable to administer to themselves this kind of basic care.

Now, in the case where death is fast approaching, time has come where a patient is no longer capable of assimilating nutrition, where force-feeding food to their system proves to be more damaging to that person's health to the point of becoming excessively burdensome; then (and only then) it becomes licit to remove said artificial means in order to allow for a natural death.

Back in 1973, in his seminal series of videoessays, The Ascent of Man, Jacob Bronowski chose to entitle the last episode, The Long Childhood. In it, he explored the offspring that are generated when science and politics sleep together. I have been thinking about this episode, today, because the whole idea of denying someone ANH seems to be a demented child of the artificial insemination of the science-politics offspring with theology.

Mixing science and politics is dangerous enough and it has ruined many a man, but throwing theology into the mix is like trying to mix a three-dimensional object with a fractal object having a dimension of 3.22. Even back in 19743, Bronowski was want to observe:

The wish to hurt, the momentary intoxication with pain, is the loophole through which the pervert climbs into the minds of ordinary men.

He could have gone one step further. Instead of the proper development of man requiring a long childhood, he could have noted that the demented can appear as children, as well. When a child cannot get his way, he makes things up. When a demented society cannot get its way, they make up new definitions.

Thou shalt not commit adultery; change what it means to be married.
Thou shalt not murder; change what it means to kill.
Thou shalt honor thy father and thy mother; hange what it means to be a father or a mother. For that matter, change what honor means. Modern society has something more in mind of the misquoting of Jesus's rebuke of the Pharisees: [Matt 15: 4-6]

But you say, 'If any one tells his father or his mother, What you would have gained from me is given to [my selfish convenience] , he need not honor his father.'

Thou shalt not steal; change what it means to steal so that stealing life is a duty.

Perhaps the biggest change is in the commandment:

Thou shalt love the Lord thy God with they whole heart, thy whole soul, and thy whole strength; change who God is and change what it means to love so that God becomes identical with any arbitrary personal definition of him and love becomes something not only arbitrary, but contradictory.

All of these things are being done to satisfy a childish whim to be in control of something that is off-limits to man: life and death. The understanding of science has met the governance of politics and blended with the aspirations of a theology to create in some modern men a sort of recessive enfeebled child that has made science into a theology, theology into politics and politics into a goulish science.

We live in an era where theology has lost control of the projector and the image has gone horribly past focus. Everybody want certainty. No one wants to live with someone else in control (and who let's God be in control anymore, these days?). Bronowski had another famous quote:

There is no absolute knowledge. And those who claim it, whether they are scientists or dogmatists, open the door to tragedy. All information is imperfect. We have to treat it with humility. That is the human condition; and that is what quantum physics says. I mean that literally" (353).

This may be the beginning of civilization's second childhood. History had proven too many optimists wrong and too many pessimists incomplete, so I won't insist on that being the case, just yet. Still, when one can call an evil good and a good evil, is not woe close at hand?

If you get the chance to watch the Bronowski series, i highly recommend it. Even he, a humanist, would be appalled at the idea that starving a weakened individual was part of the nobility of man. In his most powerful essay of the series, entitled, "Knowledge or Certainty," dressed in a black suit and tie, as he knelt down in a river outside of Auschwitz and scooped up silt which must have contained the decomposed remains of those who had been in the gas chamber, he commented:

It is said that science will dehumanize people and turn them into numbers. That is false: tragically false. Look for yourself. This is the concentration camp and crematorium at Auschwitz. This is where people were turned into numbers. Into this pond were flushed the ashes of four million people. And that was not done by gas. It was done by arrogance. It was done by dogma. It was done by ignorance. When people believe that they have absolute knowledge, with no test in reality, this is how they behave. This is what men do when they aspire to the knowledge of gods. Science is a very human form of knowledge. We are always at the brink of the known; we always feel forward for what is to be hoped. Every judgment in science stands on the edge of error, and is personal. Science is a tribute to what we can know although we are fallible. In the end, the words were said by Oliver Cromwell: 'I beseech you, in the bowels of Christ: Think it possible you may be mistaken.' We have to cure ourselves of the itch for absolute knowledge and power. We have to close the distance between the push-button order and the human act. We have to touch people.

That is what those who want to limit ANH are: afraid to touch dying people, instead, demanding that God do it for them and in the next life only, if you please.

The Chicken


Ari, I cannot help it if people want to misread what I said and twist it into something opposed to what I said. When I said "no longer worthwhile" I qualified it with "using the guidance of the CDF" and with "continued use is actually harming the patient." Given our stated explanations of these earlier, nobody who actually read these words trying to understand what I was saying (and giving me the simple honor of allowing that my saying "using the guidance of the CDF" means accepting and acting on the teaching the CDF laid out) would mistake them for anything other than just precisely the sort of scenario you were talking about, when putting food in the dying person's stomach is detrimental to their health, or completely useless for their health because they can't make use of it.

If you feel it necessary to further qualify my comment to bring just what I was saying even MORE clearly, feel free. But if someone is bent on misunderstanding the issue, neither you nor I are going to be able to prevent it.

Re-aligning my words to suggest Son A is arbitrarily deciding anything is directly and absolutely contrary to saying "using the guidance of CDF", which perforce means not arbitrarily.

Chicken, good comments. There are many illustrations of what you say. One would be Michael Schiavo's horrible statement to the effect that his wife "departed" at the time of the accident that left her disabled. How convenient. And how childish.

Tony, my one additional thought about the scenario you give is that you portrayed it as one of serious and potentially family-fracturing between Sons A & B. It seems to me that that would be the case only if they had a disagreement about the _empirical_ question: Is their mother really unable to assimilate the food and water? Speaking for myself, I would sympathize with Son B's skepticism if the only authority for the claim is a medical person, who might be biased in precisely this area. I would want more evidence than just that a nurse said that it's natural for the mother to dehydrate at the end of her life (I've actually heard that a hospice nurse said something like this to some relatives). And it would seem to me that an "err on the side of life" principle should also be guiding here, too, if it is not _very clear_ that the mother is not absorbing and processing the nutrition and hydration and that it is not even providing her any comfort. In other words, I think that if both of the sons are real sticklers on the matter of being sure not to dehydrate someone to death, they ought to be able to come to agreement on the facts and hence on what should be done.

Lydia, that is a good point, but looking at how it plays out in practice right at the very end of life (strictly within the last week or two), I am not so sure that there would ever be a time when you would have a right to 100 % confidence that the food (or, more importantly, the water) is not doing the person ANY good whatsoever. How could ANY person, no matter how well trained medically and ethically, be 100 % sure that more water simply has no benefit whatsoever?

What happens in real life is that the food stops being broken down, and passes through without being modified, gradually . There is no specific point at which one can identify: OK, the body is not absorbing even a smidgeon of this food. This is still more true of water: when could you have empirical evidence of 100 % uselessness of water?

I think that the sort of decision process and evidence presentation we are looking at is the sort where we say: To a reasonable person, this evidence is sufficient to judge with reasonable assurance that the food is not doing more than a very minimal amount of good. Whatever good it is doing as providing nutrition to the body's cells is negligible. But this does not mean that this reasonable person has 100% certainty of this fact - no empirical fact pattern could provide that conclusion.

As we see on juries all the time, reasonable people set the bar on concretely identifying "reasonable certainty" slightly differently ALL THE TIME. Generally, when two people who both have well-formed consciences and who are both well intentioned disagree on whether the actual case is reasonably certain, the looser one should give way to the stricter one. But that generic concept only holds to the extent that there are not competing goods to achieve.

If son B thinks Mom should be given water artificially for 2 or 3 more days because (although he agrees it is just a matter of a couple of days until she DOES get there), he does not yet feel fully confident that her body has completely shut off its ability to use that water; and if her throat cancer means that the artificial means has to be through a stomach tube, and Mom has evidenced such a distaste for medical intervention in the past that she will not readily tolerate a stomach tube (my grandfather at the end of his life kept pulling tubes out of his body), do these secondary facts play into the "proportionate good" that becomes the determination at some point, or are they irrelevant? Does the small but non-negligible chance that the water may still do some good for another 2 or 3 days override any concern about comfort and patient distress? Mom is out of her senses part of the time, and there is no way to be confident that she will NOT pull at the tubes unless you sedate her, and sedating her will essentially guarantee that she NEVER regain coherence at all.

It is my feeling that the proportionate good of at least a few hours of coherence and rationality here and there in her remaining few days is something we do consider as part of the proportionate goods to balance against the modest probability of benefit of a couple days worth of water. But this sort of proportionality would be explicitly weighing a physical good against the the good that additional water may prevent dehydration to some portion of the body. Is that the sort of proportion that we consider, or is it out of bounds? I say that it is proper, because the non-physical good is precisely a good of the person as such, and what we are about here is the good of a PERSON, not the good of an animal body.

I'm not demanding 100% certainty (I'm an epistemologist after all), but I would have a pretty high standard, particularly for water. As long as the kidneys are functioning and producing urine normally, it seems the fluids are being absorbed.

But if Son A and Son B are both agreed that we're talking only about a difference of two days, then they both know that we're not talking about dehydrating or starving the mother to death. That in itself should make for a significant area of agreement.

what we are about here is the good of a PERSON, not the good of an animal body.

That's an odd thing to say, as if the person and the body were separate things.

I suppose what Tony is asking is, "Should you strap Mom down or sedate the dickens out of her to keep her from trying to pull out a tube that is apparently really bugging her when she is definitely going to die within two days and hence will not be dehydrated to death if you don't continue the tube feeding?" And my answer is that, if you really know she is going to die that quickly, then no, you are not obligated to undertake unpleasant additional measures (for her) or measures that will make her less able to communicate in the last two days of her life to try to get around this problem. But you'd have to, in my opinion, have really good evidence that this _is_ the situation. For example, if she were expected to live at least a week, still absorbing at least the fluids, and could be merely mildly sedated, IMO that would be a whole different matter. IV hydration is another option to bear in mind. I have also read an interesting article that I don't know if I kept a copy of suggesting the benefits of (IIRC) subcutaneous administration of fluids as a way of hydrating people, including people in late-stage cancers, that would avoid both unnecessary dehydration toward the end of life as well as some of the disadvantages of other methods.

Btw, real-life check: Anyone in the situation Tony is describing is likely already under a certain amount of sedation for pain.

Let me be more precise on this particular of the scenario: the nurses and doctors all say that death is at the very most 3 weeks away, probably less than 2 weeks, but can't be confident it is less than one week away. Best guess is 10 to 12 days - but this is based on averages of various people, so some people in this state live 16, 18, even 20 days, some only 5.

Not looking at how much the body is able to use the water, but only at whether by depriving the body of water, will this cause death by dehydration, we might be close enough to death that it is irrelevant whether we give more water or not, or we might be far enough from death that dehydration could cause death. But our best estimates are that death is right in the middle of how long a person can live without water.

The difference of the 2 to 3 days I was talking about was that (for example) if Mom continues to decline as she has for the last 2 weeks, in another 2 or 3 days (says son B) we could be fully sure that she can no longer use the food or water. (But son A says we are reasonably sure now.) But she is more than 2 or 3 days from death, it is more like 10-12 days until death, could be as few as 5 and as many as 20 days (with very low likelihood).

By the way, the identification of how long a person can live without food and water (particularly water) varies with obvious circumstances as body size, age, and overall health, but also with such things as drive to live, and mental outlook. So when they say a person can live up to 14 days without water, what they mean is a range from roughly 7 to 14 days depending on the person and their circumstances. Do we know if that means 7 to 14 days for healthy people, less for those gravely ill? We don't really know very well how that range fits with this particular patient, other than knowing it is a range.

So what we have here are three range estimates, not one of which can be nailed down with great precision. (1) How much use can the body get from the water - maybe 1%, maybe 20%, probably somewhere in between. Certainly within 2 or 3 days it will drop to negligible, if it has not done so already. (2) How far away is death? Probably 10-12 days, give or take. (3) What period of time would Mom go until dying from dehydration if she did not die from her illness? Some value between 5 and 14 days, depending on lots of factors.

Just establishing a guesstimate that even if you withdraw water, Mom is so close to death that she will not die of dehydration in her remaining time is not a sufficient moral decider: although she wouldn't die of dehydration in her remaining time, the lack of water may contribute to dying earlier than otherwise because it damages her ability to deal with other problems. So I find this focusing in on whether Mom is within the period where a (normal) person would not die from dehydration rather puzzling. It is asking the wrong question. If her use of water was not an issue (if her body could still use the water), we would not withdraw water just because we knew death is coming within 5 days with or without the water. What if it will be 5 days with water, and 3 days without? The withdrawal of water would hasten death, even though not causing death from dehydration.

Btw, real-life check: Anyone in the situation Tony is describing is likely already under a certain amount of sedation for pain.

Maybe, I don't know. My mom was not under any significant pain medicine until 2-3 weeks before death, I can't remember exactly. She was pretty coherent a few hours a day until about 3 days before death.

I've gotta say, if someone dear to me were expected to live that long with the underlying condition, I'd take a lot of convincing before depriving him of all fluids. What mechanism can these guys be believing is operating that will kick in after two days at most (if not already) and prevent their mother from processing _even fluids_ while she continues to live for 10-12 days? I would think complete kidney failure would kill you a lot quicker than that (without dialysis, of course). It can't even be a breakdown of the digestive system alone, or she could still process IV fluids or subcutaneous fluids. If Son B is supposed to be the hard guy here, I find his set of beliefs a little surprising.

It can't even be a breakdown of the digestive system alone, or she could still process IV fluids or subcutaneous fluids.

Lydia, I am sorry, I did not take IV into account, I thought we were considering strictly the feeding tube - either nasogastric or stomach tube. (I have never even heard of subcutaneous fluids - how is that different from IV?). My thoughts have largely been about people who cannot absorb the fluids through the GI tract, not about other failures to use fluids. Once you open the floor to an IV for fluids going in, is there any rationale for not using an IV for dialysis and other filtering methods?

What mechanism can these guys be believing is operating that will kick in after two days at most (if not already) and prevent their mother from processing _even fluids_ while she continues to live for 10-12 days?

Here are some quotes: In patients with cardiac or respiratory disease, problems with fluid management may be exponentially increased. What kinds of problems arise? Edema or swelling of the legs and arms may become a problem as "water" or fluid begins to collect in tissue spaces outside of the circulatory system's arteries and veins. Unnaturally high fluid levels in the tissues can result in poor healing and susceptibility to local infections in that area of the extremity...

However, edema of another sort can be quite upsetting and even more troublesome: "pulmonary edema" or "fluid in the lungs," sometimes called the "death rattle."

Another one: This fluid is different than the one above, as this fluid comes from the body retaining too much sodium when the liver is in failure. The doctor sometimes places them on a diuretic, tells them how much fluid they are allowed to have each day and puts them on a "lower" sodium diet. They may develop a condition known as Encephalopathy. This is because the liver isn't able to handle toxins in the body like it once did. Therefore, these toxins go out into the blood and pass the barrier there and into the brain. It can cause memory problems and having a hard time to think clearly.

So that gives another example of continuing the fluids potentially being responsible for multiple other problems including hindering clear thought. Well before the end, many of these problems can be handled, but near the end a lot of body chemistry stops working well. In matters of degree.

Lydia, whatever symptoms tell you that fluid is not being managed in the body properly, they will come on in stages and in degrees. But just as the condition changes in matters of degree, the outward signs only imprecisely identify the exact condition. Therefore, there will of necessity be a set of symptoms (compatible with total complete failure but also compatible with merely near-complete failure) where the patient's state is clearly close to complete failure to manage fluids, may already be there, and if not there yet (having seen the development over time) certainly will be there soon. Some people would be comfortable calling this "reasonable certainty" that starting the use of a feeding tube (or an IV, I suppose) would be disproportionate to the situation (assuming death is within the 2-week horizon as suggested above). Other people would not.

Are you quite satisfied that the people who would claim reasonable certainty that it (using the tube) is disproportionate are making a choice which is objectively disordered? Would your conclusion change if the death horizon changed to 1 week? If so, is that because a person can survive a week before dehydrating? But then would that still be true if the amount of time THIS person can survive without "dehydration" in their weakened state and with their diseases is surely less than the 7-14 days of a normal person? Would one ever be reasonably certain that continuing fluids would not hasten the otherwise approach death until one has incontrovertible proof that continuing with fluids are damaging the body right now more than dehydration would? And wouldn't that "proof" be well past the point where the evidence just "suggests", or even "strongly suggests" that the fluids are damaging in excess of any damage from dehydration.

My whole point here (and has been since my 6:23 post of Sept 10) is that this concrete determination that there is now reasonable certainty is a judgment based on matters of degree, and therefore reasonable men may disagree. And where reasonable men may disagree, it should be possible to talk about the disagreement between them as though NEITHER of them is objectively disordered in making their conclusion. If we cannot speak about the lack of agreement without ascribing moral disorder on one side or the other, then there is something faulty in our analysis. I am NOT speaking about the obvious cases like withdrawing fluids from an unconscious person who otherwise would have months to live. By "reasonable" I mean both persons rightly adhering to true principles for upright choices, but having differing concrete conclusions.

Sorry, in my penultimate paragraph, the penultimate sentence is missing a "not". SHould be:

Would one ever be reasonably certain that NOT continuing fluids would not hasten the otherwise approach death until one has incontrovertible proof that continuing with fluids are damaging the body right now more than dehydration would?

But then would that still be true if the amount of time THIS person can survive without "dehydration" in their weakened state and with their diseases is surely less than the 7-14 days of a normal person? Would one ever be reasonably certain that continuing fluids would not hasten the otherwise approach death until one has incontrovertible proof that continuing with fluids are damaging the body right now more than dehydration would? And wouldn't that "proof" be well past the point where the evidence just "suggests", or even "strongly suggests" that the fluids are damaging in excess of any damage from dehydration.

I would say that you need very strong evidence that fluids are either harming the person more than their withdrawal would or that they are not being processed to any significant degree before you should deny all fluids. This is especially important if the person cannot drink or eat by mouth or is not going to be allowed to do so, because that removes one natural mechanism whereby the person's own bodily urges can help to insure that the person is not being dehydrated to death or caused pain by dehydration and hunger alone. Sure, phrases like "very strong evidence" and words like "significant" come in degrees. But I think that if there is good evidence regarding the empirical questions, the moral questions are not quite as difficult and complicated as you seem to envisage.

Obviously, if the person is expected to live about two weeks with water and/or food and only less one week or less without, it _isn't true_ that he is not absorbing and using the nutrition and hydration. And if you have that expectation on the basis of strong evidence, you shouldn't listen to somebody who tells you the water and food are doing more harm than good or aren't being used.

Two problems seem to me to complicate this situation. The first is what I see as an increasing reluctance to permit mouth feeding when there has been any degree at all of aspiration. I have heard that this trend may be turning around; good, if so. But when doctors are saying that somebody isn't to be allowed to eat or drink by mouth because he _might_ choke, because he has had _some_ choking bouts, and then they turn around and advise against a feeding tube as well, there's a problem. Even a dying person can often eat or drink, and if he is allowed to, that can allow truly natural processes to take place, including a natural process whereby a conscious person in end-stage cancer indicates that he isn't able to process food and fluids properly by expressing discomfort and gradually rejecting them. The second problem is the bias in the medical profession against keeping dying people well-hydrated since they are "going to die anyway," which makes it hard to know whom to trust. I would have some very careful questions about symptoms going on _right now_, not just symptoms that might come up in a few days or a week, for any doctor who tried to tell me that a loved one was not benefiting from food or fluids. There needs to be strong reason to believe it's happening now. I just wish it were possible to trust doctors and nurses more fully on this point.

Tony:

Ari, I cannot help it if people want to misread what I said and twist it into something opposed to what I said. When I said "no longer worthwhile" I qualified it with "using the guidance of the CDF" and with "continued use is actually harming the patient."

You're assuming that folks who read the CDF document would interpret it accordingly.

However, there have been several instances where folks tend to come to different interpretations all their own that are in fact contrary to what such documents actually meant and intended. This is not limited to CDF documents, papal encyclicals, the Catechism, etc.; you see this as well with Scripture, too.

This is why I felt it necessary to elaborate even further the particular circumstances the CDF document itself was addressing.

In other words, "using the guidance of the CDF" is no guarantee that the reader himself would have actually come to a sound Pro-Life conclusion.

And, while such an instance of this would admittedly be nothing more than a tortured and amazingly flawed interpretation at best, still one cannot deny that simply stating "no longer worthwhile" and "continued use is actually harming the patient" can easily entertain even those hideous mercy-killing agendas against which these documents were originally meant to oppose in the first place.

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