Recently the daughter of a man dying of cancer called the National Catholic Bioethics Center’s consultation line.1 Her father, while still able to swallow, was ingesting less and less as death approached. He had received the Anointing of the Sick and Viaticum (i.e., the Eucharist given to the dying). The daughter asked if there was a moral obligation to provide assisted nutrition and hydration as death drew near. After determining that her father’s vital organs no longer could assimilate food and water, causing the decreased appetite, the moral decision was made not to initiate assisted nutrition and hydration.
The next day the daughter called, stating that her father had died, and expressing gratitude for the advice. It was obvious that the underlying pathology, not euthanasia through starvation and dehydration, had caused his death.
Families also get advice from other sources. Tragically, some have been wrongly advised by the medical community that preserving their loved one’s “dignity” and ending their suffering require ending their life—by active intervention, or more frequently, by omitting basic care. Many families are unsure about moral options for the care of their loved ones. Fortunately, the popes and bishops of the Catholic Church have provided invaluable guidance concerning end-of-life decisions, including issues of pain control and consciousness, the provision of food and water to dying or unconscious patients, the right to refuse certain treatments, and the duty to care, even when a cure is no longer possible. In a pamphlet, one can only highlight these teachings, so readers are encouraged to read the entire statements and directives mentioned below, which are available online.
What does the Church teach about pain control and consciousness?
The Ethical and Religious Directives for Catholic Health Care Services2 (ERDs) state, “Patients should be kept as free of pain as possible so that they may die comfortably and with dignity, and in the place where they wish to die. Since a person has the right to prepare for his or her death while fully conscious, he or she should not be deprived of consciousness without a compelling reason….” In some cases, pain control may require brief or prolonged periods of unconsciousness. Pain control can be provided even if, in rare cases, the needed doses may have an anticipated, but unintended effect of hastening death.3 The intention is to control extreme pain, not to hasten death. With euthanasia, however, there is an explicit intent to terminate the patient’s life, representing a grave evil with eternal consequences.
Currently, three states allow physician-assisted suicide. Some states practice a more covert form of euthanasia, providing patients who suffer from physical or even psychological pain with high doses of sedation, when other effective relief is available. Then assisted nutrition and hydration are withheld, causing death by dehydration or starvation, not the underlying pathology. This is sometimes called “terminal sedation,” distinguishable from the legitimate use of sedation as a last resort to treat patient suffering in their last days. The difference is in the physician’s intent, whether it is to end life or control pain.
What does the Church teach about providing food and water to unconscious or dying patients?
Pope John Paul II taught: “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.”4 This principle has been affirmed by the Congregation for the Doctrine of the Faith5 and incorporated into the Ethical and Religious Directives in 2009 (n. 58).
What does the Church teach about the patient’s right to refuse or forego certain medical treatments?
The papal encyclical The Gospel of Life condemns euthanasia, drawing a key distinction between euthanasia and the decision to forego “medical procedures which no longer correspond to the real situation of the patient, either because they are by now disproportionate to any expected results or because they impose an excessive burden on the patient and his family. In such situations, when death is clearly imminent and inevitable, one can in conscience ‘refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted’” (n. 65).
It is clear that there is no moral requirement to utilize burdensome treatments that merely prolong the dying process. Unless the patient is very near death, however, the provision of nutrition and hydration, even by artificial means, should be administered as long as they can sustain life and alleviate suffering without imposing serious risks or side effects to the patient.
Today active interventions or omissions of basic care are proposed for ending the lives of not only the dying, but also patients suffering from a long-term cognitive disability, such as advanced dementia or a so-called persistent “vegetative” state. Some argue that patients who cannot consciously respond have lost their “human dignity.” This view is dangerously wrong: Human beings never lose their dignity, that is, their inherent and inestimable worth as unique persons loved by God and created in His image. People can be denied respect affirming that dignity, but they never lose their God-given dignity.
What does the Church teach about our duty to care for dying or vulnerable family members?
When a family or health care providers refuse to provide basic care (nutrition, hydration, cleanliness, warmth, and prevention of complications from confinement to bed), finding it “inconvenient” to accompany the loved one on the final journey, the assault on human dignity is grave. When such abandoning of the disabled or unconscious patient is codified in state laws, the implications for society are frightening. Pope Benedict XVI states in his encyclical In Hope We are Saved (Spe Salvi), Nov. 20, 2007: “The true measure of humanity is essentially determined in relationship to suffering and to the sufferer…. A society unable to accept its suffering members and incapable of helping to share their suffering and to bear it inwardly through ‘com-passion’ is a cruel and inhuman society” (no. 38).
Christ calls us to love one another: “This is my commandment: love one another as I love you” (John 15:12). He loved us unto death, even death on the cross. Few are called to such a sacrifice; but we are called to be companions to each other, especially to those suffering on life’s journey. “Companion” is taken from the word “cum-panis,” meaning “with bread.” Thus, we are called to share the bread of Eucharist with each other, responding with Christ’s sacrificial love. We are asked not only to care for each other, but to nourish each other, even unto death.
Dr. Hilliard is the director of bioethics and public policy for The National Catholic Bioethics Center. She is a canon lawyer and a registered nurse.
1The National Catholic Bioethics Center provides a 24 hour ethics consultation service, free of charge: 215-877-2660.
2 United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, 5th Ed. (2009) n. 61.
3 John Paul II, Encyclical The Gospel of Life (Evangelium Vitae), March 25, 1995, n. 65.
4 Pope John Paul II, Allocution “On Life-Sustaining Treatment and the Vegetative State”, March 20, 2004, n. 4.
5 Congregation for the Doctrine of the Faith, Responses to Certain Questions of the United States Conference of Catholic Bishops Concerning Artificial Nutrition and Hydration, 2008.