Bioethics Discussion Blog: The Pope and Directed Food and Fluid Administration vs “Fundamental Human Dignity”

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Sunday, September 23, 2007

The Pope and Directed Food and Fluid Administration vs “Fundamental Human Dignity”

For those who are unaware, there came a response about a week ago from the Vatican to the concerns of the Catholic Bishops in the United States regarding Pope Benedict XVI”s statement earlier related to the administration of food and fluid to a patient who is permanently unconscious in a so-called “permanent vegetative state”. The following response was prepared by the Congregation for the Doctrine of Faith and approved by the Pope.



CONGREGATION FOR THE DOCTRINE OF THE FAITH
RESPONSES TO CERTAIN QUESTIONSOF THE UNITED STATES CONFERENCE OF CATHOLIC BISHOPSCONCERNING ARTIFICIAL NUTRITION AND HYDRATION

First question: Is the administration of food and water (whether by natural or artificial means) to a patient in a “vegetative state” morally obligatory except when they cannot be assimilated by the patient’s body or cannot be administered to the patient without causing significant physical discomfort?

Response: Yes. The administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life. It is therefore obligatory to the extent to which, and for as long as, it is shown to accomplish its proper finality, which is the hydration and nourishment of the patient. In this way suffering and death by starvation and dehydration are prevented.

Second question: When nutrition and hydration are being supplied by artificial means to a patient in a “permanent vegetative state”, may they be discontinued when competent physicians judge with moral certainty that the patient will never recover consciousness?

Response: No. A patient in a “permanent vegetative state” is a person with fundamental human dignity and must, therefore, receive ordinary and proportionate care which includes, in principle, the administration of water and food even by artificial means.

The Supreme Pontiff Benedict XVI, at the Audience granted to the undersigned Cardinal Prefect of the Congregation for the Doctrine of the Faith, approved these Responses, adopted in the Ordinary Session of the Congregation, and ordered their publication.


Rome, from the Offices of the Congregation for the Doctrine of the Faith, August 1, 2007.
William Cardinal LevadaPrefect
Angelo Amato, S.D.B.Titular Archbishop of SilaSecretary



This means that the Pope has directed that physicians and healthcare providers must provide all patients who are permanently unconscious, not expected to ever recover consciousness, food and fluid by natural (impossible in an unconscious patient) or artificial by intravenous or tube method against medical judgement and against the request of the patient or surrogate who has officially made a statement to the contrary. refusing at some point further food or fluid. This directive presumably would be followed by every Catholic hospital in the world and would, of course, apply to all patients whether Catholic or not. What do you think about this directive and whether, in some cases, by denying a patient’s autonomous decision about their own healthcare actually represents ignoring and not supporting a “fundamental human dignity.”? The other concern is whether the directive will be applied to all patients who refuse food and fluid, even those who are conscious. ..Maurice.

19 Comments:

At Sunday, September 23, 2007 2:53:00 PM, Blogger MJ_KC said...

I very much do not appreciate any politicians or religious leaders imposing their opinions on doctors and patients.

 
At Sunday, September 23, 2007 4:26:00 PM, Blogger LisaMarie said...

Eeeggghh...I already have worries about whether or not my living will will actually be followed should bad things happen. Should I also worry that it should say "Don't take me to a Catholic hospital!" I've heard conflicting things about how much good having a legal document will even do should the situation arise, and here's just another thing for people who are concerned about having their wishes honored to worry about. I personally don't think it upholds fundamental human dignity, but then I'm not Catholic and I place the autonomy of the individual higher on the list of important values than the Church seems to. I don't believe it's possible to uphold someone's dignity on their behalf by doing things to them that they don't want. As for patients who are conscious, wouldn't that be battery?

 
At Sunday, September 23, 2007 4:36:00 PM, Blogger Maurice Bernstein, M.D. said...

MJ KC, does your view include politicians who set laws based on their decision as to when an embryo becomes a person, under what conditions a physician may terminate life-support of a patient who has requested the treatment stopped, or as another example. punishing physicians who in good faith and with a basis for treatment prescribe marijuana to a cancer patient? If politicians and religious leaders impose their opinion on doctors and patients, what should doctors and patients do--ignore the impositions? ..Maurice.

 
At Sunday, September 23, 2007 4:46:00 PM, Blogger Maurice Bernstein, M.D. said...

LisaMarie, I would think it would be legally considered battery even if food or fluid were forced on an unconscious patient in a persistent vegetative state, in addition to, as you state, a conscious patient. ..Maurice.

 
At Sunday, September 23, 2007 7:38:00 PM, Blogger MJ_KC said...

Laws should be very generic and when the law wants to impose its will on people it should have the same burden of proof as a guilty verdict in a criminal case.

The court would have to prove beyond a shadow of a doubt that their judgment is superior to the patient's and doctor's judgment. When a living will is involved, that should be the final say in the matter.

I have been treated for two kinds of cancer and would have appreciated anything that would have made me feel better. That includes the active ingredients in marijuana in a non-cigarette form.

I am personally pro-choice when it comes to abortion, but this is not a critical issue to me. There are much more important things to consider when choosing who to vote for. This is quite a ways down the list of things to consider.

I would never expect a doctor to risk getting in trouble in order to follow a patient request.

 
At Monday, September 24, 2007 10:11:00 AM, Anonymous bob koepp said...

Maurice - My main concern here is that nutrition/hydration will be provided even to individuals who, if they were conscious, would flatly reject this treatment. So much for respecting the dignity of individuals...

But, I don't see where the Pope's statement suggests that n/h should be provided "against medical judgment." He says it should be provided as long as it accomplishes it proper finality, namely "hydration and nourishment of the patient," which is precisely the normal medical rationale for n/h.

 
At Monday, September 24, 2007 11:08:00 AM, Blogger Maurice Bernstein, M.D. said...

Bob,nutrition and hydration(n/h) can always be "shown to accomplish its proper finality [in the Pope's sense] which is the hydration and nourishment of the patient." Fluids will deminish any dehydration present and nutrition will add nourishment in terms of calories, protein, fats and vitamins to the body. Of course, how the body deals with this "nourishment" is another matter and, in fact, that is the very matter that makes up the physician's decision. From a medical standpoint, the "proper finality" of n/h is not simply placing stuff into the body but the "proper finality", in psycho-pathophysiologic terms, is the psychologic benefit of food and fluid (the pleasure of eating) and the ability of n/h to restore the individual to some degree of recovery from the underlying pathologic process. In the case of patients with persistent vegetative state, there is NO psychologic benefit and there is NO recovery. This is where the decision by the physician and patient/surrogate is in conflict with the Pope's directive. ..Maurice.

 
At Monday, September 24, 2007 5:09:00 PM, Blogger MY OWN WOMAN said...

Where does all this leave people who have a Medical Durable Power of Attorney? Can the hospital just override decisions made by the patient?

I can sign out of the hospital AMA, but I can't refuse nourishment and hydration? Am I missing something here?

 
At Monday, September 24, 2007 6:20:00 PM, Blogger Maurice Bernstein, M.D. said...

What will become the final policy setting what will occur in any Catholic hospital will depend, as I understand it, on the decisions by the local Bishops. They are aware of the state and U.S. laws and the views of their parishoners.
If a hospital is required to follow the Pope's directive, it will be responsible to notify all patients along with their families about to enter the hospital about their religious directive so that they, if they desire, may go elsewhere. If the patient was admitted as an emergency, the patient would have to be transferred to another institution if food and fluid was to be administered over the patient's objections.

However, as I have already suggested, it is doubtful that any hospital would force food and fluid on an unwilling patient since this could easily be considered physical abuse and battery no matter how hydrating and nourishing the Pope finds this treatment to be or how worthy this act is to "preserve human dignity". ..Maurice.

 
At Tuesday, September 25, 2007 6:36:00 AM, Anonymous Anonymous said...

While it's about what you would expect from the current church leadership, I wouldn't be overly concerned. There is a huge difference between using religious grounds to refuse to perform an elective procedure (ie: abortion), versus forcing an unwanted treatment such as food/hydration on a patient.

The American Bishops aren't stupid, they'll most likely pay some lip service to the issue then let it die quietly. The courts have routinely held that where there is a conflict between cannon and civil law, civil law prevails. In all probability they would lose any criminal or civil actions brought as a result, and they don't need any more bad publicity.

As an aside, while this was issued with Papal approval, it has Levada's dirty little finger prints all over it. TT

 
At Tuesday, September 25, 2007 7:34:00 AM, Blogger Stephen Drake said...

Not so coincidentally, I blogged Friday and yesterday about this. Yesterday's blog entry deals with the "sky is falling reactions."

http://notdeadyetnewscommentary.blogspot.com/2007/09/more-on-vatican-statement-on-tube.html

BTW, I was waiting until I was comfortable with keeping up with the blog until I started opening it up for comments. I figure I'm ready enough and the blog will open its "comments" option by the end of the week.

 
At Tuesday, September 25, 2007 7:42:00 AM, Anonymous bob koepp said...

Maurice - I tried posting a response yesterday, but was apparently unsuccessful. In it, I questioned your suggestion that the purpose or "proper finality" of n/h has anything to do with the psychological benefit of pleasures associated with eating and drinking. I also questioned whether it is true that n/h can always be shown to serve their physiological purpose, since in some circumstances the patient might not be able to assimilate them (as noted in the first question posed by the US Bishops). I think withholding n/h from a patient who can't assimilate it in a straightforward physiological sense would be consistent with the Pope's statements.

That said, I'd like to reiterate that what _does_ concern me about the Pope's position is that it undermines patient/surrogate autonomy -- i.e., it undermines whatever dignity accrues to us in virtue of being moral agents.

 
At Tuesday, September 25, 2007 7:51:00 AM, Blogger Maurice Bernstein, M.D. said...

I took my silly Google survey of website opinion by entering in Google search terms either the words within quotes "The Pope is Right" or "The Pope is Wrong" and here are the results of the survey taken today 7:50 am Pacific Time.

"The Pope is Right" 10,900 sites
"The Pope is Wrong" 1010 sites

Do what you want with the statistics. ..Maurice.

 
At Tuesday, September 25, 2007 9:44:00 AM, Blogger Maurice Bernstein, M.D. said...

Bob, I think one has to define what "assimilate" means. If assimilae means "to consume and incorporate (nutrients) into the body after digestion
or to transform (food) into living tissue by the process of anabolism; metabolize constructively" then all common nutriments will do some or all of that and fluids will provide hydration.

Bob, providing a therapy really requires two considerations. The basic consideration is the efficacy of the therapy to accomplish the main goal in therapy which is to restore the ill patient back to a quality of life which the patient has made known or if not known that quality of life which an average person would want. If after weighing the risks of the therapy, if the therapy is not expected to do that then it should not be administered.
This is a longer term consideration of the use of the therapy.

The second consideration in selecting therapy is the shorter term use where the long term prognosis is good or unknown and the quality of life considerations of the patient with therapy are acceptable to the patient or unknown. With that consideration, after weighing the risks, the therapy may be administered in order to provide its anticipated more immediate pharmacologic or physiologic benefit and to simply preserve life.

If a patient, in a permanent vegetative state, had previously requested that food and fluid be withheld, it was because the patient had recognized that the therapy would not accomplish the patient's goal of return to an acceptable quality of life irrespective of the preservation of life by the therapy.

Anyway, this is how I look at the decisions. ..Maurice.

 
At Wednesday, September 26, 2007 8:23:00 AM, Blogger Maurice Bernstein, M.D. said...

To help explain my last posting about the two phases of making a decision regarding treatment, some years ago there was an interesting scenario presented in the Hastings Center Report as I recall. A homosexual male who was HIV positive entered a hospital emergency room with his partner because of acute onset of cough and shortness of breath and fever. The patient was seen by the ER doctor who, based on the history and exam, suspected an acute pneumonia most likely related to the patients HIV infection. The physician explained that this might be the first illness of AIDS. (This was before the current effective AIDS treatments were available.) The patient and his partner showed the physician an advance directive written by the patient which stated that under no circumstances should the patient be put on a ventilator. The partner was to be the patient’s surrogate to make decisions if the patient was unable. The ER doctor was satisfied with and accepted that request since he felt and explained to the patient and his partner that the patient’s pneumonia could be easily treated with an antibiotic and that use of a ventilator would be unlikely. The partner left and the doctor ordered the ER nurse to begin treatment with an antibiotic injection. She gave the injection but a few minutes later the patient suddenly became much more short of breath, started turning blue and then suddenly became unconscious, apparently suffering an anaphylactic reaction to the antibiotic. The nurse immediately gave an antihistamine injection and called the physician who arrived and instantly knew that the patient should be intubated quickly and put on a ventilator in order to survive. He was about to order the treatment when he remembered the advance directive by the patient stating that under no circumstances should he be put on a ventilator. The issue was what should the physician do next? The patient and partner had never been informed that a eaily reversible anaphylactic reaction might occur requiring transient use of the ventilator. If he obeyed the directive, the patient would most likely die. If he intubated the patient and put him on the respirator, he would be going against the autonomous request of the patient but it was very likely that the patient would recover from the anaphylaxis within minutes or an hour and the ventilator could be removed and the pneumonia could be easily treated with full recovery. Did the patient ever consider while writing that advance directive that the use of a ventilator might be life-saving but only transient and that the patient’s quality of life would not be changed and if considered the patient might have made an exception? But what if the pneumonia was aggravated by the acute allergic reaction and the patient had to be on the ventilator indefinitely? There was no time for the doctor to try to contact the partner and inform the partner that quick recovery was possible on ventilation but otherwise the patient would die. A decision had to be made. Did “No” really mean “No”? Should the doctor go ahead and intubate, stabilize the patient, call the partner, explain and if the partner still refused ventilation treatment, the ventilator could be removed? On discussion of this case with my medical students, there was a mixed reaction but the majority felt that the patient should be intubated and ventilated until the partner decided.

Here, the first decision was the short term decision, the prognosis was good for both recovery from the anaphylaxsis and the pneumonia and a truly informed decision by the patient was immediately unavailable the use of the ventilator would be life-saving and should be started. The second decision was a longer term decision and involved the patient’s desire for a certain quality of life, irrespective of the immediate therapeutic benefit of ventilation. Perhaps the patient would feel that if he was to die from AIDS, he should die without living through all the misery of the later stages of AIDS. Therefore if the overall prognosis was poor or the patient,having been fully informed, had decided that the quality of life would be unsatisfactory that even if the treatment was physiologically effective, it should not be started. What decision would you have made if you were the ER doc? ..Maurice.

 
At Wednesday, September 26, 2007 10:42:00 AM, Anonymous Anonymous said...

Intubate, then call the partner immidiately and explain what is happening. Inform the hospital of the 'problem.' But what happens if what seems to be a reaction to the antibiotic progresses into something worse? Maybe set a time limit that if patient is not better in XX days, remove the ventilator.

 
At Wednesday, September 26, 2007 11:26:00 AM, Anonymous Anonymous said...

Dr. B,

The scenario you described brings up some interesting points.

Hindsight being 20/20, first and foremost in my mind is the issue of informed consent. In any instance where there is potential for a severe anaphylactic reaction to a medication, the patient should be informed of the possibility, potential degrees of severity and what the treatment would be to counteract the reaction. In my mind it is incumbent on the physician to be proactive and deal with the issue ahead of time, especially when they know there is an advanced directive in place. A simple "I'm going to prescribe XXXX antibiotic to treat your pneumonia. Even if you haven't had one in the past, there's a possibility you may have an allergic reaction. Most of these are relative mild, in the form of an itching or rash & if that happens we can give you something to alleviate that. Rarely, a patient may have a more severe reaction that makes it difficult or impossible to breathe on their own, and we may have to use a breathing tube for a short period of time until the counteracting medication takes effect. Is this OK with you?" This is a classic example of where taking a few extra seconds up front can prevent a prevent later on. While having your students discuss the scenario and the decision making process from an ethical standpoint is unquestionably a valuable exercise, they should also be looking at it from a root cause failure standpoint - ask themselves what could have been done differently.

The other issue you correctly raised is what is a person's true intent when they execute an advanced directive. The provisions of advance directives vary from state to state, but basically what they say is that under circumstances where a person is close to death & not likely to recover, permanently unconscious, or in an advanced stage of a progressive illness that will be fatal, the person specifies what actions in terms of nutrition/hydration/life support (including CPR) they do or don't want to be implemented. At face value this would appear to exclude the scenario you described, but I don't think it's smart to make assumptions......

People executing an advanced directive need to express their intent, and there is usually a place on the form under "additional considerations or instructions" where they can do this. They also need to discuss this with their physician to make sure there is a clear understanding of their desires. My personal standard is return to "status quo ante" - in other words, if I can't come back all the way, don't bring me back at all.

Getting back to the original topic of this thread, I am a lifelong Catholic. I have no problem at all with artificial means of birth control, including sterilization if that is the individuals wish. While I don't personally believe in abortion, I don't believe that I have the right to tell others what to think or do - it's up to them to decide what is right for themselves. I support capital punishment for certain crimes. I have twice voted in favor of the "death with dignity" act, which is now law in our state. I also have an advanced directive that precludes the use of nutrition, hydration & life support
under the circumstances outlined, and I couldn't care less what "il Papa" and his band of merry men have to say about it......and if you look around, I'm betting that I'm pretty typical of the majority of mainstream American Catholics. Bottom line...the Vatican can say what it wants, but the American Bishops know that the rank and file Catholics don't support it. TT

 
At Thursday, September 27, 2007 7:26:00 PM, Blogger Maurice Bernstein, M.D. said...

Those visitors to this thread may be interested in the conflict between the Vatican and an Italian anesthesiologist,Lina Pavanelli, who has recently suggested in a journal and otherwise publicly that the behavior of Pope John Paul II's physicians prior to his death was essentially one of providing euthanasia or assisted suicide. The story is written in the International Herald Tribune. Her argument was that the starting Pope's artificial feedings were unusually delayed despite its need in a Parkinsonian patient who had trouble swallowing. ..Maurice.

 
At Tuesday, October 02, 2007 7:43:00 PM, Blogger Maurice Bernstein, M.D. said...

For those visitors interested in listening to a discussion by a palliative care physician at Massachusetts General Hospital Grand Rounds dated Oct 2 2007 regarding tube feeding in palliative care of Alzheimer's patients click here.

I agree generally with the physician's approach to the issue. I did find that her presentation of the Catholic view on artifical hydration and nutrition was not up to date. ..Maurice.

 

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